Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin
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Persons who are at high risk for developing type 2 diabetes (DM2) include persons with elevated fasting and 2-hour postprandial glucose levels (ie, above normal but not qualifying as frank diabetes). Whether interventions such as weight loss, exercise, or pharmacotherapy can reduce the incidence of development of DM2 has been little studied, with the exception of recent information pertinent to reduction in new onset DM2 among vasculopathic recipients of ramipril. Knowler and colleagues randomly assigned nondiabetic persons (n = 3234) with an elevated glucose (fasting and postprandial) to either placebo, metformin (850 mg b.i.d.) or lifestyle modification (at least 150 minutes of physical activity such as brisk walking per week), and weight reduction to maintain at least a 7% loss of initial body weight. Subjects were followed for an average of 2.8 years.
Only about half of the subjects intended for 7% weight loss were able to do so; similarly, between half and two-thirds of subjects maintained assigned levels of physical activity. Nonetheless, subjects assigned to lifestyle modification demonstrated a 58% reduction in incidence of DM2. Metformin treatment also reduced the incidence of new onset DM2 by 31%.
Lifestyle intervention can prevent the onset of DM2 in high-risk individuals. Pharmacotherapy with metformin also substantially reduces risk. Whether combining the interventions would have an even greater effect is unknown.
Knowler WC, et al. N Engl J Med. 2002;346:393-403.
Eradication of Helicobacter pylori and Risk of Peptic Ulcers in Patients Starting Long-Term Treatment with NSAIDs
There are a variety of patient groups that require long-term therapy with NSAIDs, such as arthritis sufferers. That traditional NSAIDs can produce an increased risk of significant GI bleeding has been well demonstrated. It is also known that, independent of NSAIDs, the presence of Helicobacter pylori (HEL) infection in the GI tract is a primary risk factor for development of GI bleeding. Whether pre-emptive eradication of HEL in persons embarking upon a long-term course of NSAID treatment will reduce occurrence of ulcers has not been previously determined.
Chan et al studied 128 patients with arthritis who were HEL-positive by breath testing, randomized to receive either an active treatment (omeprazole 20 mg + amoxicillin 1 g + clarithromycin 500 mg b.i.d. × 1 week) or placebo. All patients began a course of diclofenac slow-release 100 mg QD for 6 months. Frequency of ulcer and complicated ulcer (ie, associated with bleeding) was assessed endoscopically.
Over 6 months time, almost 3 times as many persons in the control group (34.4%) demonstrated any ulcers than in the HEL-eradication group (12.1%). Complicated ulcers were even more skewed in favor of active treatment (4.2% vs 27.1%). Based upon this data, clinicians may wish to screen persons in whom long-term NSAID treatment is planned.
Chan FK, et al. Lancet. 2002;359:9-13.
Physiotherapy for Patients with Mobility Problems More than 1 Year After Stroke: A Randomized Controlled Trial
For stroke victims who suffer a subsequent decrement in mobility (ie, falls, difficulty in walking, problems getting out of a chair), consequences of such disability are potentially substantial. Typically, primary care clinicians may refer such persons for treatment by physiotherapists (PT), though there is a paucity of data confirming the benefits of such intervention. Green et al identified a population of stroke patients (n = 359) with persistent dysmobility at least 1 year later. Intervention by a community PT was supplied and compared with no treatment (patients were randomized).
The PTs treatment consisted of traditional physical therapy interventions, applied at least 3 times over 13 weeks. Primary outcome was assessed by the Rivermead mobility index.
Although PT did result in a statistically significant different change in Rivermead mobility index at 3 months, the difference was not a clinically relevant one. Unfortunately, by 6 months and 9 months, no difference was discerned. Additionally, PT did not reduce the number of falls. Whether other forms of PT will provide meaningful benefit to stroke victims with persistent dysmobility remains to be determined.
Green J, et al. Lancet. 2002;359: 199-203.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
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