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On The Pulse - October 2018

On The Pulse

Tertius Lydgate

Friday, 26 October 2018

Dual antiplatelet therapy after drug-eluting stent implantation
Treatment with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is used to prevent thrombotic closure of the vessel after stent implantation and, due to high rates of stent thrombosis, treatment has been given for 12 months. But a study in The BMJ questioned this approach, particularly since the introduction of second generation drug-eluting stents which drastically reduced the risk of stent thrombosis. The non-inferiority trial, which looked at the safety of limiting DAPT for six months, enrolled 1,100 patients with STEMI aged 18 to 85 who underwent a primary PCI with the implantation of second generation drug-eluting stents and who were event free at six months. Participants were randomised 1:1 to single antiplatelet therapy (SAPT) (i.e. aspirin only) (n=432) or to DAPT (n=438) for an additional six months. The primary endpoint (a composite of all-cause mortality, any myocardial infarction, revascularisation, stroke, and thrombolysis in myocardial infarction major bleeding at 18 months after randomisation) occurred in 4.8% of patients receiving SAPT versus 6.6% of patients receiving DAPT (HR 0.73, 95% CI 0.41 to 1.27). Non-inferiority was met as the upper 95% confidence interval of 1.27 was smaller than the prespecified non-inferiority margin of 1.66. The results therefore suggest shorter DAPT is safe for patients with STEMI.

Drug–herb and drug–supplement interactions
As polypharmacy is a recognised patient safety risk among older adults, researchers writing in the BJGP set out to establish the prevalence of concurrent prescription drugs, herbal medicinal products (HMPs), and dietary supplements among UK community-dwelling older adults and identify potential interactions. Out of 400 questionnaires posted to older adults aged ≥65 years and identified as taking ≥1 prescription drug, 155 were returned showing a prevalence of concurrent use of 33.6%. Females were more likely than males to be concurrent users (43.4% vs 22.5%). The number of HMPs and dietary supplements ranged from 1 to 8 (mean= 3). The majority of concurrent users (78.0%) used dietary supplements (most commonly: cod liver oil, glucosamine, multivitamins, and vitamin D) with prescription drugs. Others (20.0%) used only HMPs with prescription drugs, such as evening primrose oil, valerian, and Nytol Herbal®. 16 participants (32.6%) were at risk of potential adverse drug interactions. The authors conclude GPs should routinely ask questions regarding herbal and supplement use, to identify and manage older adults at potential risk of adverse drug interactions.

Should we stand more at work?
It is well known that a sedentary lifestyle increases risks of developing chronic diseases such as type 2 diabetes, cardiovascular disease and some cancers, along with a reduction in mental wellbeing. A randomised controlled trial in The BMJ evaluated the impact of an intervention designed to reduce sitting time in desk-based workers on their physical, psychological and work-related health. The intervention group (n=77) received a height adjustable workstation along with motivational materials, coaching tools and self-monitoring forms, whereas the control group (n= 69) continued usual practice. Significant differences between groups, in favour of the intervention group, was found in occupational sitting time at 3, 6 and 12 months. Group differences, in favour of the intervention group, were also found for prolonged sitting time, standing time, job performance, work engagement, occupational fatigue, sickness presenteeism, daily anxiety, and quality of life. No differences were seen for sickness absenteeism. The authors conclude the intervention is successful in reducing sitting time and is associated with positive changes in work-related and psychological health.  

Poisoning substances taken by young people
As poisonings account for most medically-attended self-harm globally, a study in the BJGP set out to assess poisoning substance patterns and trends among 10–24-year-olds across England to help inform self-harm prevention. The open cohort study of 1,736,527 young people identified 40,333 poisoning episodes, with 57.8% specifying the substances involved. The most common substances were paracetamol (39.8%), alcohol (32.7%), NSAIDs (11.6%), antidepressants (10.2%), and opioids (7.6%). Poisoning rates were highest at ages 16–18 years for females and 19–24 years for males. Opioid poisonings increased fivefold from 1998–2014, antidepressant poisonings three-to fourfold, aspirin/NSAID poisonings threefold and paracetamol poisonings threefold in females. Overall, poisoning incidence was higher in more disadvantaged groups, with the strongest gradient for opioid poisonings among males. The authors point out the importance of raising awareness with families of the substances young people use to self-harm, especially the common use of over-the-counter medications. They suggest quantities of medication prescribed to young people at risk of self-harm and their families should be limited, particularly analgesics and antidepressants.

B-blocker therapy in pregnancy and malformation risk
Beta-blockers are commonly used in pregnancy with hypertension, where treatment is required. A cohort study in the Annals of Internal Medicine sought to estimate the risks of major congenital malformations associated with first-trimester exposure to β-blockers. Of 3,577 women with hypertensive pregnancies in the Nordic cohort and 14,900 in the US cohort, 682 (19.1%) and 1,668 (11.2%), respectively, were exposed to β-blockers in the first trimester. The pooled adjusted relative risk (RR) and risk difference per 1,000 persons exposed (RD1000) associated with β-blockers were 1.07 (95% CI, 0.89 to 1.30) and 3.0 (CI, −6.6 to 12.6), respectively, for any major malformation; 1.12 (CI, 0.83 to 1.51) and 2.1 (CI, −4.3 to 8.4) for any cardiac malformation; and 1.97 (CI, 0.74 to 5.25) and 1.0 (CI, −0.9 to 3.0) for cleft lip or palate. For CNS malformations, the adjusted RR was 1.37 (CI, 0.58 to 3.25) and the RD1000 was 1.0 (CI, −2.0 to 4.0) (based on US cohort data only). Results suggest that use of beta-blocker therapy in the first trimester is not associated with a large increase in risk of malformations.  

Anti-TNF treatment in patients with hand osteoarthritis
Patients with osteoarthritis of the hand commonly present to clinicians but have limited treatment options. As inflammation of the joint is often seen in patients, a one-year trial in the Annals of Rheumatic diseases sought to evaluate tumour necrosis factor (TNF) as treatment target. Patients with erosive inflammatory hand osteoarthritis with flare after non-steroidal anti-inflammatory drug washout were randomised to etanercept (24 weeks 50mg/week, thereafter 25mg/week) or placebo. The mean between-group difference (MD) in Visual Analogue Scale pain was not statistically significantly different (−5.7 (95% CI −15.9 to 4.5) at 24 weeks; − 8.5 (95% CI −18.6 to 1.6) at one year; favouring etanercept). In prespecified per-protocol analyses of completers with pain and inflammation at baseline (n=61), MD was −11.8 (95% CI −23.0 to −0.5) at one year. Etanercept-treated joints showed more radiographic remodelling and less MRI bone marrow lesions; this was more pronounced in joints with baseline inflammation. Results show that anti-TNF did not relieve pain effectively after 24 weeks, but a small group showed some signal for effects on subchondral bone in actively inflamed joints, which would warrant further research. 

Influenza A: another cause of SIADH?
BMJ Case Reports present a case of influenza A that may have caused a profound SIADH-related hyponatraemia. The syndrome of inappropriate antidiuretic hormone (SIADH) secretion is a frequent cause of hyponatraemia. It is a dilutional hyponatraemia secondary to impaired urinary dilution in the absence of renal disease or any identifiable non-osmotic stimulus known to induce antidiuretic hormone secretion. SIADH can arise secondary to various respiratory tract infections; however, the association between SIADH and influenza A infection is rarely described in the literature. In this case, a 66-year-old man was diagnosed with influenza A and SIADH after presenting to the emergency department with a one-week history of dry cough and progressively worsening dyspnoea, generalised myalgias, fever, chills and rigors. The authors call on clinicians to be aware of the possible association between SIADH secretion and influenza A.

Forecasting health scenarios: what does the future holds?
As health and social-services planning and investments require consideration of possible future trends in health and corresponding drivers, The Lancet has published a study that provides a novel approach to modelling life expectancy, all-cause mortality and cause of death forecasts — and alternative future scenarios — for 250 causes of death from 2016 to 2040 in 195 countries and territories. The authors say that while the reference forecast points to overall improvements through 2040 in most countries, the range found across better and worse health scenarios renders a precarious vision of the future — a world with accelerating progress from technical innovation but with the potential for worsening health outcomes in the absence of deliberate policy action. They suggest decision makers should plan for the likely continued shift toward non-communicable diseases and target resources toward the modifiable risks that drive substantial premature mortality. Communicable, maternal, neonatal, and nutritional diseases causes and related risks remain however the predominant health priority among lower-income countries. They also warn of a real risk of HIV mortality rebounding if countries lose momentum against the epidemic.

Author's Image

Tertius Lydgate

Originally from Northumberland, Tertius Lydgate studied medicine in Edinburgh, London and Paris. There he developed a special interest in communicable diseases and hoped to make great advances in treating and preventing them. But, after a promising start in a provincial centre of excellence in middle England, he was forced by circumstances (please, don't inquire) to abandon his high ideals. He now scrapes a living by pouring cold water on the over-enthusiastic at his private cryohydrotherapy clinic. Dreaming of the contributions he once hoped to make himself, he finds consolation in the latest medical journals and is happy to share his discoveries with his readers. He thinks that his creator, George Eliot, would have approved.
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