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.

Use of High-Dose Acyclovir in Pityriasis Rosea

Although it has been long suspected that pityriasis rosea (PTR) is of viral origin, proof of that remains lacking. Recent evidence suggests that herpes virus 6 (HSV 6) and herpes virus 7 (HSV7) are etiologic in PTR. Antiviral therapy such as acyclovir (ACV) has proven effective for management of other HSV infections, but it is not clear whether PTR is treatment-responsive. Indeed, PTR is often treated with watchful waiting or antipruritic medication, on the basis that it is usually self limited. Nonetheless, because HSV6 has been associated with increased risk for abortion, were antiviral treatment effective for PTR, treatment might be worth considering on this basis coupled with potential symptom reduction.

Consecutive patients (n = 82) with typical dermatologic findings of PTR underwent serologic evaluation for HSV6 and HSV7. Other bacterial and viral agents which might produce similar dermatologic findings were included in serologic analysis (eg, Borellia, toxoplasmosis). Patients were alternately assigned to either ACV treatment (800 mg five times daily for one week), or placebo in a single-blind fashion.

On day 7, regression of PTR skin lesions was seen in 90.5% of the ACV treatment group vs 26.7% in the placebo group. New lesions appearing beyond one week were seen in none of the treatment group, and 40.5% of the placebo group. By 2 weeks, complete lesion regression was seen in 78.6% in the ACV group, but only 4.4% in the placebo group.

PTR-associated symptoms, eg, fatigue, headache, sore throat, irritability, insomnia, and nausea, followed a similar course: by day 7, none of the placebo recipients were fully symptomatically resolved compared with 36.8% in the ACV group. These data suggest that ACV treatment may be helpful in PTR.

Drago F, et al. J Am Acad Dermatol. 2006;54:82-85.

Rimonabant in Overweight or Obese Patients

Despite a growing public and professional awareness of the health consequences of overweight, there is little in the way of pharmacologic management to provide a meaningful impact on excess body weight. Recently, interest has been expressed in capturing the influence of the endocannabinoid system, which has receptors in the CNS, adipose tissue, muscles, GI tract, and liver. Stimulation of the cannabinoid-1 receptor results in increased eating, decreased muscle mass, and lipogenesis. Rimonabant (RIM) is a cannabinoid-1 receptor blocker, and has shown favorable effects upon both body weight and some of the metabolic consequences of overweight. The RIO-North America study is a randomized, controlled trial of RIM in adult overweight or obese individuals.

Through 2002, subjects were enrolled and randomly assigned to either RIM 5 mg/d, RIM 20 mg/d, or placebo. After 1 year, subjects who had received RIM were rerandomized to drug or placebo; the original placebo group continued on placebo. All subjects were also placed on a diet.

RIM 20 mg/d produced favorable results at 1 year which were statistically significantly different from placebo: a reduction of body weight 6.3 kg, reduced waist circumference, increase in HDL, and reduction in triglycerides. Subjects who were switched from RIM to placebo in year 2 lost much of the favorable weight and metabolic changes attained in year 1, but those who remained on RIM 20 maintained these positive effects. Rimonabant is a promising method of modulating excess weight and attendant metabolic derangements.

Pi-Sunyer FX, et al. JAMA. 2006;295: 761-775.

Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men

Inguinal hernia (ING) in men is rarely associated with serious adverse outcomes. Nonetheless, because ING can result in bowel incarceration and strangulation, there is some uncertainty about the propriety of watchful waiting (WW). Some men are motivated to intervene surgically because of pain or cosmetic effects; but the study by Fitzgibbons et al suggests that a conservative approach for men with minimal symptoms is appropriate.

The randomized trial included adults with ING (n = 720) who were randomized to surgical repair or WW. Subjects were followed for 2-4.5 years. Among those assigned to WW, 23% ultimately elected surgical repair during the study, most commonly due to increased pain; a similar percentage (17%) in the group originally randomized to surgery chose instead to use WW.

At 2 years, the primary end point (pain interfering with activity) was the same in the WW as the surgical group. Only 2 patients in the WW group who were followed for up to 4 years sustained incarceration.

The authors conclude that WW is a reasonable strategy for managing ING because serious adverse events are rare, and other clinical outcomes are similar with either approach.

Fitzgibbons RJ, et al. JAMA. 2006;295:285-292.