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By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Botulinum Toxin for Treatment of Hyperhidrosis
Persons who do not suffer hyperhidrosis (HID) may be surprised to learn that it has been associated with both occupational and physical impairment, as well as limitations in social interaction. Some success in managing primary axillary hyperhidrosis may be achieved with topical agents, systemic pharmacotherapies, and/or surgical intervention, but many patients continue to have inadequately controlled symptoms, or are dissatisfied with available methods.
The release of sweat from eccrine glands is mediated by acetylcholine through cholinergic neurons. Injected botulinum toxin type A (BTX) produces transient blockade of the cholinergic nerves that supply sweat glands.
Patients with primary axillary HID were randomized in a double-blind, placebo-controlled trial of treatment with BTX. Each subject received BTX or placebo and was followed for symptom control at weeks 1, 4, 8, and monthly thereafter. Subjects could elect an additional BTX injection, but not sooner than 8 weeks after the last injection.
Most of the BTX subjects (75%) reported a major improvement in HID symptoms (at least a 50% improvement in the Hyperhidrosis Disease Severity Scale). The median duration of positive effect was greater than 6 months. There were no significant adverse effects that differed between BTX and placebo (placebo was an injection of sterile saline). BTX has a favorable efficacy and tolerability profile, and should be useful in management of HID.
Lowe NJ, et al. J Am Acad Dermatol. 2007;56:604-611.
A Fish Story
Two major intervention trials have shown that consumption of fish (either in the diet, or by means of fish-oil supplement) is effective in secondary prevention of coronary events post-MI. Long-chain fatty acids in fish—specifically eicosapentanoic (EPA) and docosahexanoic acid (DHA)—have been shown to be inversely related to CAD mortality.
The population of Japan has a diet high in fish. Whether the addition of EPA to this diet would impact coronary events in dyslipidemic patients was the clinical question addressed by JELIS: The Japan EPA Lipid Intervention Study.
JELIS was a prospective randomized placebo-controlled trial in hypercholesterolemic men and women (n = 18,645), all of whom were already receiving statin treatment (specifically, pravastatin or simvastatin). Subjects were assigned to either EPA (1,800 mg/d) or placebo for 5 years. The primary endpoint was any major coronary event.
After a mean followup of 4.6 years, there was a statistically significant 19% relative risk reduction in the primary endpoint for persons on EPA compared to placebo. When the population was separated to look at effects in those with pre-existing CAD vs without, it was discerned that only the former group had a statistically significant benefit, although the trend for event reduction even in the primary prevention group looked promising (18% relative risk reduction). EPA/DHA supplements offer benefit even in persons with diets commonly high in fish, and already on a statin.
Yokoyama M, et al Lancet. 2007; 369:1062-1063
Diabetes Control: It's More Than Just A1c Control
In our zeal to refine glucose control in diabetes to attain microvascular risk reduction, we sometimes overlook an equally relevant attribute: better glucose control helps patients feel better! Quality of life (QOL) studies have generally demonstrated QOL improvements with better glucose control. Does it make a difference how you get better control? That question was addressed by Vinik and Zhang in their randomized trial of glargine (GLAR) vs Rosiglitazone (ROSI).
Subjects with uncontrolled type 2 diabetes despite full therapeutic doses of metformin and a sulfonylurea were randomized to add either GLAR or ROSI, and followed for 6 months. In addition to monitoring changes in control of diabetes (A1c), a health-related quality of life instrument was used to measure outcomes.
GLAR and ROSI provided similar improvements in A1c (1.5% - 1.66% reduction). Numerous differences in QOL were evident however, favoring GLAR: total symptom distress score, mood symptoms, ophthalmologic symptoms, fatigue, and perception of general health.
Clinicians have been sometimes reluctant to initiate insulin therapy for persons with uncontrolled diabetes. These data suggest that insulin treatment not only provides substantial A1c improvements, but—with comparable glucose control—resulted in better QOL improvements that ROSI. How we gain control of type 2 diabetes may make a difference.
Vinik AI, Ahang Q. Diabetes Care 2007;30(4):795-800.