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By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Sucampo Pharmaceuticals, Takeda, Boehringer Ingelheim; and is a consultant and on the speaker's bureau for Novo Nordisk, Lilly, Daiichi Sankyo, Forest Pharmaceuticals, Cephalon, Novartis, and Sanofi Aventis.
Remission of type 2 diabetes with bariatric surgery
Source: Wilson JB, Pories WJ. Durable remission of diabetes after bariatric surgery: What is the underlying pathway? Insulin 2010;5:46-55.
The burgeoning population of individuals with type 2 diabetes corresponds to a parallel increase in obesity. Although bariatric surgery produces prompt and sustainable weight loss, the post-surgical rapidity with which derangements of diabetes resolve defies explanation by weight loss alone.
Bariatric surgical procedures that eliminate food contact with the duodenum and jejunum as opposed to gastric banding type procedures produce not only substantial weight loss, but also provide remission of type 2 diabetes within days. Indeed, as many as 80% of type 2 diabetes patients leave the hospital with no diabetes medications, and more than 75% remain diabetes-free 5 years later. Similar reversion to normal glucose handling has also been seen in patients with impaired glucose tolerance who have bypass surgery.
Post-surgical benefits of bariatric surgery include resumption of normal menstrual function, BP and lipid improvements, and reductions in diabetes-related mortality. Studies of gastric banding conclude that weight loss is responsible for these favorable outcomes. In contrast, bariatric bypass surgery, although enjoying benefits attributable to weight loss, has other operant mechanisms: One report of intestinal bypass in lean type 2 diabetics found resolution of diabetes without weight loss.
The GI tract has been increasingly recognized as a critical player in glucose dysregulation, as evidenced by evolution of the incretin mimetics and DPP-4 inhibitors. Resolution of dysglycemia within a few days prior to meaningful weight loss is characteristic of bariatric bypass surgery.
Ipratropium and cardiovascular events in COPD
Source: Ogale SS, et al. Cardiovascular events associated with ipratropium bromide in COPD. Chest 2010;137: 13-19.
Bronchodilators (i.e., inhaled beta agonists and anticholinergics) are the foundation of symptomatic care for COPD. Metered-dose inhaler administration of ipratropium (IPR) is generally very well tolerated, and associated with few, if any, adverse symptoms. Nonetheless, there remains some conflict about the cardiovascular safety of anticholinergic bronchodilators in COPD. One meta-analysis suggested as much as a 53% increased relative risk for MI in COPD patients treated with IPR; in contrast, a large randomized prospective trial with tiotropium (n = 6000, approximately) did not find any signal for increased cardiovascular events.
Ogale et al performed a cohort study comprised of newly diagnosed COPD patients (n = 82,717) attending an Illinois VA hospital.
Risk for a cardiovascular event was 29% higher in COPD patients treated with IPR than comparators. Risk was time-related: Those with at least a 6-month interval since last exposure to an anticholinergic were not at greater risk. The mechanism by which anticholinergics might increase cardiovascular risk is not clear, although a dose-response relationship between IPR and supraventricular tachyarrhythmia incidence noted in the Lung Health Study intimates a possible connection.
BP response of atenolol vs HCTZ
Source: Beitelshees AL, et al. Comparison of office, ambulatory, and home blood pressure antihypertensive response to atenolol and hydrochlor-thiazide. J Clin Hypertens 2010;12: 14-21.
In untreated subjects with hypertension (HTN), 24-hour ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBP) have been shown to provide better indication of risk than office blood pressure (OBP). On-treatment BP measurement using the same techniques shows similar associations: ABPM is better than HBP, which is better than OBP for risk prediction. Since not all patients can be availed of ABPM, HBP monitoring has received increased advocacy.
HCTZ and atenolol (ATN) are two of the most commonly prescribed antihypertensive agents in the United States. Beitelshees et al performed a randomized controlled trial to assess the relative accuracy of OBP and HBP compared to the gold standard ABPM in subjects (n = 418) treated with HCTZ, atenolol, or the combination.
For both systolic and diastolic BP, correlation with ABPM was significantly better for HBP than OBP. For example, OBP overestimated treatment effects on SBP by 4.6 mm Hg compared with HBP. Recent HTN consensus groups have endorsed routine HBP monitoring; these data support the role of HBP monitoring as a better risk predictor than OBP.