Oral Triptans in Acute Migraine Treatment: A Meta-Analysis of 53 Trials
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Migraine is a commonplace disorder that typically results in recurrent attacks of disabling headache. Triptans have become the foundation of abortive therapy for most migraneurs, yet little guidance is available to choose the most appropriate triptan from among the available, and soon to be available, agents. In this meta-analysis, Ferrari and colleagues reviewed data from 24,089 patients who had been included in double-blind, randomized, controlled clinical trials of oral triptans in migraine.
Sumatriptan (SUM) is the most widely used triptan, and hence serves as the most convenient and familiar comparator. Efficacy measures included response at 2 hours, pain free at 2 hours, recurrence within 24 hours, and sustained pain-free status (free of headache at 2 hours, without recurrence within 24 hours).
Eletriptan (ELE) demonstrated a higher placebo-subtracted 2-hour response rate and pain free at 2 hours rate than SUM, but frovatriptan (FRO) was slightly less efficacious than SUM for response at 2 hours. Sustained pain- free status was statistically significantly greater for rizatriptan (RIZ), ELE, and almotriptan (ALM). Placebo-subtracted adverse events rates were significantly lower for ALM.
As a group, all triptans demonstrate similar efficacy and adverse event profiles. Modest differences between agents might be helpful in initial product selection.
Ferrari MD, et al. Lancet. 2001;358: 1668-1675.
Simvastatin and Niacin, Antioxidant Vitamins, or the Combination for the Prevention of Coronary Disease
It has been suggested that cardiovascular risk is separately and independently related to both changes in LDL and HDL. The oft-quoted relationship between lipid subfractions suggests that for each 1% reduction in LDL, one might achieve a 1-1.5% decline in cardiovascular end points, and that for each 1% increase in HDL a 2-4% reduction in cardiovascular end points. This study (n = 160) evaluated the hypothesis that for persons with existing coronary artery disease (CAD), lipid-altering and antioxidant treatments might provide independent and additive benefits. Inclusion criteria included established CAD plus a low HDL.
Treatments received by the subjects included simvastatin, slow-release niacin, and/or antioxidants (800 IU vitamin E, 1000 mg vitamin C, 25 mg beta carotene, 100 µg selenium daily). Patients were followed for 3 years, with end points of stenosis status and clinical cardiovascular events.
Risk of death from coronary causes, confirmed MI or stroke, or revascularization for worsening ischemia (the composite primary end point of the trial) was 90% lower in the simvistatin + niacin group than the placebo group. No statistically significant effects were shown for use of antioxidants. Brown and colleagues suggest that the combination of simvastatin and niacin may represent a major advance of traditional monotherapies, and that there is little to support the commonplace practice of antioxidant supplementation for CAD modulation.
Brown BG, et al. N Engl J Med. 2001; 345:1583-1592.
Decreased Rate of Coronary Restenosis After Lowering of Plasma Homocysteine Levels
The potential etiologic relationship of homocysteine (HCST) to cardiovascular disease end points has generated much recent scrutiny. There has not been a major clinical trial indicating that homocysteine modification effects cardiovascular outcomes. Schnyder and colleagues examined the effect of folic acid-based treatment (FBT)—ie, 1 mg folic acid, 400 mcg vitamin B12, and 10 mg pyridoxine daily—upon post-coronary angioplasty patients (n = 205) administered over 6 months.
FBT produced a 35% reduction in homocysteine levels (from 11.1 to 7.2). Minimal luminal diameter was greater and degree of stenosis was less severe in FBT recipients. FBT treatment produced an impressive halving of the rate of restenosis, and a comparably favorable reduction in the need for revascularization of the target lesion.
Administration of moderate supplementation with folic acid, vitamin B12, and pyridoxine is inexpensive and well tolerated. Schnyder et al suggest that such treatment should be considered "adjunctive therapy" after coronary angioplasty. Though folate is likely to be the most prominently involved constituent, it is possible that pyridoxine and/or vitamin B12 also exert effects.
Schnyder G, et al. N Engl J Med. 2001;345:1593-1600.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
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