Clinical Briefs
December 15, 2016 3 minutes read
A Link Between Obesity and Asthma Severity
SOURCE: Bhatt NA, Lazarus A. Obesity-related asthma in adults. Postgrad Med 2016;128:563-566.
Asthma, like hypertension, may be more than one entity. That is, more than one underlying pathophysiology may lead to similar phenotypic expression. Just as hyperaldosteronism may present with hypertension that is otherwise indistinguishable from “essential hypertension,” might the clinical presentation of asthma reflect various underpinnings?
It perhaps has been underappreciated that risk for development of asthma increases as body mass index increases over 25 kg/m2, that obese asthmatics may be more treatment resistant, and that obese asthmatics experience higher rates of asthma-related hospitalizations (with worse outcomes).
Mechanistically, obesity-related asthma (ORA) is characterized by less occurrence of atopy and eosinophilia. Perhaps this helps explain the observation that steroid responsiveness is lower in ORA patients. Other features of inflammation differ in ORA vs. atopic asthma, such as interleukin levels.
Determining which aberrant inflammation circuitry in ORA deserves intervention to improve ORA outcomes is not yet clear. On the other hand, there are very encouraging prospective randomized trial data confirming improvements in asthma achieved through weight loss in obese patients. Clinicians should be aware that individualization of treatment for ORA may need to include attention to weight reduction to optimize outcomes.
Low-dose OTC Proton Pump Inhibitor for GERD Relief
SOURCE: Peura D, Le Moigne A, Pollack C, et al. A 14-day regimen of esomeprazole 20 mg/day for frequent heartburn: Durability of effects, symptomatic rebound, and treatment satisfaction. Postgrad Med 2016;128:577-583.
Esomeprazole is available over the counter as Nexium 24 (20 mg) and by prescription as Nexium 40 mg. More than 75% of patients with uncomplicated gastroesophageal reflux disease (GERD) enjoy symptomatic relief with a four- to eight-week course of prescription esomeprazole 40 mg daily, and many of the remainder find improvement with twice-daily dosing.
Might even a lower esomeprazole dose over the short term be effective? To test this hypothesis, Peura et al performed two clinical trials in which they randomized subjects to 20 mg esomeprazole or placebo daily for two weeks. The remarkable thing about the patient population is that subjects were excluded if they received a confirmed diagnosis of GERD or erosive esophagitis or were on a prescription for GERD medications. One might perceive such patients as those with insufficiently burdensome symptoms to seek clinician care for relief. Study subjects reported frequent heartburn at least two days/week for the past month.
Daily low-dose esomeprazole (20 mg) was statistically significantly superior to placebo for symptom relief during 14 days of administration and the week following discontinuation, without evidence of rebound. When patients do not achieve satisfactory symptomatic relief from GERD with low-dose treatment, appropriate courses of action include increasing the dose, switching to another proton pump inhibitor, adding an H2 antagonists, or adding an alginate.
Home BP Monitoring Associated with Better BP Control
SOURCE: Erden S, Mefkure Ozkaya H, Banu Denizeri S, Karabacak E. The effects of home blood pressure monitoring on blood pressure control and treatment planning. Postgrad Med 2016;128:584-590.
Intuitively, incorporation of home blood pressure monitoring (HBPM) into the regimen of BP control interventions should improve outcomes. Encouraging patients to take ownership of their BP management, elimination of white-coat hypertension, and the ability to detect overtreatment by identification of episodes of hypotension at home could improve outcomes of hypertensive patients. But does HBPM improve outcomes?
Erden et al retrospectively evaluated charts of 1,006 hypertensive Turkish adults, of which 40% participated in HBPM. They compared several outcomes: office BP, percent achieving BP control (defined as < 135/85 mmHg), and vascular health (cardiovascular [CV] events and retinopathy).
The HBPM group was statistically significantly more likely to achieve BP control (85% vs. 56%). More difficult to explain is the polarity of vascular results: CV events actually were statistically significantly more common in the HBPM group, whereas retinopathy was less common. While the HBPM group, on average, had been treated for hypertension for a substantially longer duration (nine years vs. seven years), this would not reconcile why one vascular compartment (retina) showed favorable effect, whereas CV events did not, especially since a ponderous amount of clinical trial data shows a consistent relationship between office BP lowering and CV outcomes.
In this section: connecting asthma to obesity; finding the right treatment for uncomplicated gastroesophageal reflux disease; and better blood pressure control.
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