Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Abbott, AstraZeneca, Boehringer Ingelheim, Daiichi, Sankyo, Forest Pharmaceuticals, Lilly, Novo Nordisk, Takeda.
Extended-release Carvedilol + Lisinopril in Hypertension
Source: Bakris GL, et al. Effect of combining extended-release carvedilol and lisinopril in hypertension. J Clin Hypertens 2010;12:678-686.
Since the publication of the allhat trial, clinicians have progressively relied upon diuretic-based regimens to manage hypertension (HTN). On the other hand, in the ALLHAT trial, overall mortality was similar with diuretic, calcium channel blocker, or ACE inhibitor, lending credence to the idea that any of the treatment choices is reasonable, at least for the endpoint of all-cause mortality. There was no beta blocker arm in the ALLHAT trial; instead, beta blockers were used as add-on treatment.
Ultimately, only a small minority (about 25%) of patients with HTN are able to be controlled with monotherapy. Hence, clinicians must feel comfortable taking best advantage of available combinations of treatment. The COSMOS Study (Coreg and Lisinopril Combination Therapy in Hypertensive Subjects) randomized 656 hypertensive patients to treatment with extended-release carvedilol, lisinopril (LIS), or both. Each agent, as monotherapy or in combination, was used in the full range of therapeutic doses (e.g., LIS 10 mg, 20 mg, and 40 mg).
Although perhaps counter-intuitive, it was only when the highest doses of combination therapy were compared with highest-dose monotherapy that an advantageous differential of diastolic BP lowering was seen. This is the first clinical trial to combine these specific agents, and the fact that simultaneous initiation of both medications was very well tolerated is reassuring.
When Should a Non-diabetic A1c Be Rechecked?
Source: Takahashi O, et al. A1c to detect diabetes in healthy adults: When should we recheck? Diabetes Care 2010;33:2016-2017.
Recently, the ada has advocated the use of A1c to diagnose diabetes, indicating that we may now make a diagnosis of diabetes with an A1c ≥ 6.5. We do not have explicit guidance about the frequency with which persons whose A1c falls below the diagnostic threshold should be rechecked.
Takahashi et al followed all adults participating in preventive health check-ups (n = 16,313) at the Center for Preventive Medicine at St. Luke's International Hospital, Tokyo, from 2005 to 2008. Three years after enrollment, among those without diabetes at baseline, 3.2% had reached an A1c ≥ 6.5. However, the likelihood of progressing to diabetes varied widely and was dependent upon the baseline non-diabetic A1c: Only 0.05% of persons with an A1c < 5% became diabetic vs 20% of those with an A1c 6.0%-6.4% at baseline.
Based upon their observations, the authors suggest that if baseline A1c is < 6.0%, rescreening is unlikely to be valuable in less than 3 years. On the other hand, the high frequency of A1c progression when baseline A1c is 6.0%-6.4% merits consideration of annual rescreening.
Office-based Colon Cancer Screening?
Source: Nadel MR, et al. Fecal occult blood testing beliefs and practices of U.S. primary care physicians: Serious deviations from evidence-based recommendations. J Gen Intern Med 2010;25:833-839.
Colon cancer screening (ccs), when properly done, has been shown to improve outcomes. Unfortunately, available screening methods suffer from underutilization, misinterpretation, and inappropriate follow-up.
Nadel et al compared data obtained from the National Survey of Primary Care Physicians' Recommendations and Practices for Cancer Screening during two time intervals (1999-2000 and 2006-2007), compiling responses from PCPs (n = 1134).
Before exploring the results, it is important to note recommendations about CCS. First, in-office screening of samples obtained through digital rectal examination (DRE) is not a recommended strategy; a single, in-office fecal occult blood testing subsequent to DRE will miss 95% of advanced neoplasia. Rather, annual CCS by means of three separate stool samples collected at home is appropriate: ACS guidelines suggest annual screening by three out-of-office samples tested with high-sensitivity guaiac or FIT.
One-fourth of primary care physicians reported using a single in-office sample in 2006-2007, down from one-third in 1999-2000. Low-sensitivity guaiac utilization decreased in the same interval from 77.4% to 61.1%.
Since the publication of the allhat trial, clinicians have progressively relied upon diuretic-based regimens to manage hypertension (HTN).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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