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By William T. Elliott, MD, FACP
Thiazide diuretics are associated with a lower risk of ischemic strokes in hypertensive patients compared to other antihypertensives. A recent population case-control study from the Group Health Puget Sound showed a higher risk of stroke with beta-blockers, calcium channel blockers, and ACE inhibitors compared with thiazides. Klungel and associates suggest that this study is consistent with previous findings and support the use of thiazides diuretics as first-line therapy for hypertension (Arch Intern Med 2001;161:37-43).
Look up "statin" on any search engine and you’ll find an astonishing number of studies published in the last six months regarding the potential benefits of this remarkable class of drugs. For example, recent data suggest that statins may reduce the risk of ischemic stroke (Circulation 2001;103.387-392), reduce the risk of diabetes in middle aged men (Circulation 2001;103:357-362), reduce one-year mortality if started early after acute myocardial infarction (AMI) (JAMA 2001;285:430-436), reduce bone fractures and osteoporosisis in the elderly (JAMA 2000;283:3205-3216; Lancet 2000;355:2185-2188), and even prevent dementia (Lancet 2000;356:1627-1631). Statins are now well established as effective in the role of primary prevention of coronary artery disease (CAD) so that high cholesterol levels are beginning to be treated as we have treated high blood pressure for the last 40 years. Side effects are few—some patients get myositis and there is the lingering concern that the drugs may somehow adversely affect cognitive function (Am J Med 2000;108:538-553), but in general, they are well tolerated. Statins are expensive, but with more "me-too" statins coming onto the market and the eventual loss of patent protection for the older statins (lovastatin is scheduled to lose patent protection later this year), the cost will surely decrease, making the drugs affordable for almost everyone. And indeed, we may someday find that almost everyone is on one of these remarkable drugs.
Medical androgen suppression and orchiectomy are both useful treatments for advanced prostate cancer in men. And while the treatments are equivalent, orchiectomy is clearly falling out of favor as men look to find any alternative to castration. A new study compares the two therapies with regard to cost and confirms what most managed care companies have known for years, that orchiectomy is significantly less costly than regular injections of leuprolide or other LH-RH agonists. Using 1999 average wholesale drug costs fo LH-RH agonist therapy, the cost of medical therapy exceeded surgical treatment at about five months, and over the 10 years of the study, costs were almost 20 times higher for medical vs. surgical therapy (J Urol 2001;165:104-107). Whether the cost issues will outweigh psyco-social issues is up for debate.
Intravenous IIb/IIIa inhibitors have become mainstays in the management of CAD. But according to a new study, oral forms of these drugs may result in increased mortality. Researchers from the Cleveland Clinic perfomed a meta-analysis of four large-scale, placebo controlled, randomized trials involving oral IIb/IIIa inhibitors and found a highly significant increase in mortality associated with the drugs. Three oral agents were used in the four studies, and an excess in mortality was seen with each, regardless of the dose or whether aspirin was used concomitantly. The increase in mortality was not attributed to an increase in myocardial infarction; however, an increase in bleeding was associated with use of the drugs (Circulation 2001;103:201-206).
Every once in a while, a nontraditional treatment proves to be worthwhile. This may be the case with glucosamine sulfate for the treatment of osteoarthritis (OA). A new study from Belgium randomized more than 200 patients with knee OA to 1500 mg of glucosamine once a day or placebo for three years. At the end of the study, the glucosamine group had less joint space narrowing and an improvement in symptoms (Lancet 2001;251:251-256). Studies are also beginning in this country. The University of Utah was recently given a $14 million grant from the National Center for Complementary and Alternative Medicine (NCCAM) to study the glucosamine sulfate in conjunction with chondroitin for the treatment of knee arthritis. Both agents are available over the counter.
Lean hypertensive patients have worse cardiovascular outcomes compared to obese hypertensives. A study from New York suggests that this may be because lean patients have greater activity in the renin-angiotensin and sympathetic nervous system during exercise. In their study, lean hypertensives had higher renin activity, higher norepinephrine concentrations, and less arterial compliance. Weber and colleagues suggest that lean hypertensives should be considered different from obese hypertensives and should be treated with drugs that block renin and modify the sympathetic nervous system (J Am Coll Cardiol 2001;37:169-174).