Clinical Briefs by Louis Kuritzky, MD
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Vitamin D and Hypertension
Source: Bhandari SK, et al. 25-hydroxyvitamin D levels and hypertension rates. J Clin Hypertens 2011;13:170-177.
Let's make this simple: vitamin d deficiency causes EVERYTHING. Well, at least that's the way things seem these days. In addition to the widespread awareness that insufficient vitamin D as demonstrated by measurement of serum 25-hydroxy-vitamin D is rampant, maladies from all spheres of medicine are increasingly recognized to be associated, to one degree or another, with vitamin D. Today, it is hypertension.
Bhandari et al begin their discussion of the relationship between vitamin D and hypertension (HTN) by pointing out that as many as 40% of U.S. adults are vitamin D deficient. Epidemiologic analyses suggest that all-cause mortality is lower in vitamin D supplemented persons. Because vitamin D is involved with the renin-angiotensin-aldosterone system, it does not require a great stretch of the imagination to visualize a vitamin D-HTN linkage.
The data studied by the authors include 2,722 adult members of the Southern California Kaiser Permanente health care system. Rates of HTN were compared with quartiles of vitamin D. A linear and inverse relationship between vitamin D status and HTN was observed, such that individuals in the lowest vitamin D quartile were almost three times as likely to have HTN as those in the highest quartile.
Whether vitamin D supplementation could improve blood pressure or prevent development of HTN remains to be determined. In the meantime, add another item to the growing list of health issues in some way linked to vitamin D status.
Amitriptyline vs Duloxetine for Diabetic Peripheral Neuropathic Pain
Source: Kaur H, et al. A comparative evaluation of amitriptyline and duloxetine in painful diabetic neuropathy. Diabetes Care 2011;34:818-822.
Diabetic peripheral neuropathic pain (DPNP) is challenging because not only does it induce a substantial pain burden, but also the pain is typically worse at night resulting in sleep deprivation and exacerbated by activity, compromising the ability of patients to perform the exercise that is so critical in weight control. Although only two drugs have received specific FDA approval for management of DPNP (pregabalin, duloxetine), clinicians often use drugs off-label, including amitriptyline. Few head-to-head trials are available with which to compare various commonly used agents.
Kaur et al performed a double-blind crossover trial of amitriptyline (up to 50 mg/d) vs duloxetine (up to 60 mg/d) in 58 study subjects. The primary outcome was patient-assessed global efficacy at 6 weeks.
The outcomes with duloxetine and amitriptyline were essentially equivalent, and tolerability was also quite similar, although dry mouth was statistically significantly more common with amitriptyline. Comparable improvement in sleep was also seen with both medications. Since amitriptyline is available generically at a low price, it presents a viable therapeutic alternative for patients whose dry mouth is not a limiting adverse effect.
Testosterone Replacement in Diabetes and the Metabolic Syndrome
Source: Jones TH, et al. Testosterone replacement in hypogonadal men with type 2 diabetes and/or metabolic syndrome (the TIMES 2 Study). Diabetes Care 2011;34:828-837.
Both metabolic syndrome (MBS) and type 2 diabetes (DM2) have been consistently found to be associated with low testosterone (TST) levels. Several new formulations of topical TST have become available in the last few years, simplifying treatment of hypogonadism. Jones et al studied the effects of TST 2% gel daily applications in hypogonadal men with MBS or DM2 treated for 1 year.
TST replacement produced numerous favorable effects in these hypogonadal men, including improvements in insulin resistance, a reduction in A1c, and lower LDL and lipoprotein A. Decreased libido and reduced sexual function are the most common presenting symptoms of hypogonadism, and numerous clinical trials have confirmed a prompt, sustained favorable response in these domains, which was similarly confirmed in this trial.
Tolerability of TST 2% gel was similar to placebo. When adverse effects did occur, more than 96% were considered mild or moderate. Cardiovascular (CV) events were seen more often in the placebo group, a reassuring finding since another trial published recently found a disarmingly marked increase in CV events in frail, senior men treated with TST.
In addition to improving target symptoms for which hypogonadal men seek relief, TST replacement can provide several other favorable metabolic effects in persons with DM2 or MBS.Let's make this simple: vitamin d deficiency causes EVERYTHING.
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