By Louis Kuritzky, MD
Metformin and Thiazolidinedione Use in Medicare Patients with Heart Failure
With expert guidance encouraging increasingly austere levels of A1C control for diabetics, clinicians have been required to become more sophisticated and diversified in diabetes (DM) pharmacotherapy. Although insulin sensitizers such as metformin (MET) and the thiazolidinediones (TZD) have played a progressively more prominent role in DM control, heart failure (CHF) is a listed precaution for TZDs and contraindication to MET use.
Masoudi and colleagues analyzed data obtained from the National Heart Care Project, an initiative to improve quality of care for hospitalized CHF patients. In a sample population (n = 12,505) from 1998-1999, approximately 7% of patients discharged with a diagnosis of CHF received prescription for TZD or MET, despite the precautionary labeling for both. A comparative sample from the same population obtained 2 years later (n = 13,158) indicated that not only had TZD/ MET prescribing not shown greater conformity to existing prescribing recommendations, but rather the number of persons receiving either drug had actually increased to 11% (MET) and 16 % (TZD).
Prescription of MET or TZD to patients with CHF presents a recognized risk. Even if some of the provision of these medications is based upon the belief that the benefits of the medication for DM outweigh the risks for worsening CHF, there likely remain a number of patients who receive inappropriate treatment because of lack of clinician awareness. Masoudi et al endorse enhanced adherence to recommended precautionary guidance for patients with CHF and DM, until studies prove whether such treatment can be safely used.
Masoudi FA, et al. JAMA. 2003;290:81-85.
Alcohol Consumption Patterns and Biologic Markers of Glycemic Control Among 459 Women
Several decades of observational data have indicated that moderate alcohol consumption (ALC) is associated with reduced incidence of cardiovascular end points, particularly stroke and myocardial infarction. The relationship between ALC and glycemic control has been less clearly established. Using the population enrolled in the Nurses Health Study II (n = 116,671), a prospective cohort study, Kroenke and colleagues studied the relationship between ALC and glycemic control in healthy women, specifically excluding individuals who had preexisting cardiovascular or other serious disease. In addition to stratification of drinking behaviors, women were categorized by BMI.
The most common alcoholic beverage chosen in this population was white wine. ALC was found to relate inversely with A1C levels, when adjusted for multiple covariates. There was no difference in the relationship when analyzed for a particular type of alcoholic beverage, nor did it make a difference whether ALC occurred with meals or in other venues. Potential mechanisms for the association of ALC with improved A1C include alcohol-induced increases in insulin binding factors, reduced hepatic gluconeogenesis, and increases in plasma leptin levels, which may decrease appetite for sweets. Kroenke et al conclude that 1-2 drinks on several days per week are associated with favorable effects on glucose homeostasis.
Kroenke CH, et al. Diabetes Care. 2003;26:1971-1978.
Azelaic Acid Gel as a New Treatment for Papulopustular Rosacea
Rosacea (ROS), although sometimes called "acne rosacea," is unrelated pathophysiologically to acne. The pathology of ROS is characterized by vascular, inflammatory, and tissue proliferative components which results in one or more of flushing, erythema, telangiectasia, inflammatory lesions, edema, localized cutaneous swellings, and ocular symptoms. Currently available treatments for ROS include systemic antibiotics, topical antibiotics, and oral isotretinoin, each of which has its own limitations and adverse effects profile. Initial observations have indicated some potential efficacy of azaleic acid, which is recently available in a gel formulation, for ROS.
This report compared azaleic acid gel (AZA) with vehicle in ROS in 2 separate randomized, controlled trials.
AZA was applied twice daily for 12 weeks, after a suitable washout period from prior treatments. Subjects (n = 664) had moderate ROS (mild and severe patients were excluded). Severity of ROS was stratified a 5-point scale, with 1 including compete remission, and indicating severe disease (and hence a deterioration from baseline). AZA gel provided a statistically significant improvement over vehicle, with approximately half of treated individuals showing disease resolution or marked improvement. In the AZA-treated patients, 38% experienced transient, mild-moderate cutaneous burning, stinging, or itching. Such symptoms were considered severe in < 1%.
AZA gel has been demonstrated to be a safe and effective treatment for ROS.
Thiboutot D, et al. J Am Acad Dermatol. 2003;48:836-845.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
Metformin and Thiazolidinedione Use in Medicare Patients with Heart Failure; Alcohol Consumption Patterns and Biologic Markers of Glycemic Control Among 459 Women; Azelaic Acid Gel as a New Treatment for Papulopustular Rosacea
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