Clinical Briefs
Clinical Briefs
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.
Treatment of Periodontitis and Endothelial Function
That there is a link between inflammation and atherosclerosis is no longer in dispute. Whether modulation of inflammation might change the process of atherosclerosis, or even better, reduce vascular endpoints, remains a challenging question. To date, efforts to reduce inflammation by means of anti-oxidants, reduction of homocysteine or antibiotics have not proven to favorably alter the course of vasculopathy.
Periodontitis (PDT) is a common inflammatory process often seen at midlife and beyond, and observational studies indicate an association with endothelial dysfunction, atherosclerosis, and cardiovascular endpoints. PDT merits treatment in its own right, and its treatment might reduce the systemic and hence vascular—burden of inflamation.
A single-blind randomized trial was performed to compare the impact of intensive periodontal disease treatment (i-PDT) vs community-based treatment (c-PDT) as a control. All patients had severe PDT.
At six months, the group which received i-PDT showed significantly greater flow-mediated brachial artery dilation (indicative of improved endothelial function) than the control group.
PDT is associated with elevated CRP, fibrinogen, and cytokine levels. This data suggests that skillful intensive management of PDT may produce benefits beyond improved oral hygiene.
Tonetti MS, et al. N Engl J Med 2007;356:911-920.
Does Cost-Conscious Prescribing Hamper Clinical Outcomes?
Limited resources require skillful utilization of the most cost-effective resources that will achieve desired clinical outcomes. Policies in the UK have recently put greater focus on the opportunities to achieve similar outcomes with less expensive medications. Whenever medications are switched, even when a "class effect" is anticipated, clinicians would like to be assured that there is no cost-efficacy trade-off.
The National Health Service Primary Care Practice in Hertfordshire, UK provided an opportunity to study the impact of two simultaneous medication switches in a geographically localized population.
Seventy patients originally on atorvastatin were switched to an equipotent dose of Simvastatin (SIMVA). Excluding one patient who developed new SIMVA-associated visual symptoms, all the others were followed for 10 months. During this time there was no significant change in total or HDL cholesterol. The calculated savings, adjusted for additional time spent by pharmacists and explanation time by physicians associated with the switch, still added up to over $20,000 in one year.
Patients (n = 115) on Losartan were switched to equipotent doses of candesartan (CAN). At follow up, systolic BP was slightly better with CAN, otherwise BP was unchanged, and no serious outcomes (eg, MI, stroke) were attributable to medication change. In one year, the practice netted savings greater than $20,000.
These data are reassuring that within class medication substitution may be cost-saving without compromising patient well-being.
Usher-Smith JA, et al. Int J Clin Pract 2007;61(1):15-23.
Macrolide-Resistant Streptococci Induction
Resistance of pathologic streptococci (pStrep) to macrolide antibiotics produces barriers to successful outcomes. In theory, the longer half-life of AZI might predispose to greater risk for development of resistance than CLA, but this remains to be conclusively established.
Commensal non-pathologic streptococcal flora (np-Strep), because they possess similar macrolide resistance genes as pStrep, provide a useful and readily accessible model to evaluate the effects of macrolide antibiotics on resistance.
Healthy volunteers (n = 244) were randomized to CLA (500 mg qd for 3 days), AZI (500 mg b.i.d for 7 days) or placebo with appropriate blinding and masking of doses. Macrolide resistance was assessed in over 1000 pharyngeal samples obtained over a 180 day interval.
In the first 28 days after drug administration, there was a statistically significantly greater percentage of resistant strep in persons receiving AZI than CLA (17.4% more common in the former). However, by the study final measurement point (180 days), there was no difference between the antibiotic groups in overall frequency of resistant strains.
On the other hand, the presence of the erm gene is indicative of high-level resistance to macrolides: AZI did not impact levels of erm gene; CLA induced a 2.5 fold increase in this gene by 180 days.
Macrolide antibiotics induce prompt and enduring effects on genetic patterns of resistance. This knowledge should help shape therapeutic choices for patients having recently received macrolides.
Malhotra-Kumar S, et al. Lancet.2007;369:482-490.
That there is a link between inflammation and atherosclerosis is no longer in dispute. Whether modulation of inflammation might change the process of atherosclerosis, or even better, reduce vascular endpoints, remains a challenging question.Subscribe Now for Access
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