Modifying the Home Environment to Prevent Falls

SOURCE: Keall MD, et al. Lancet 2015;385:

Falls in the home setting are a commonplace source of serious injury. In the recent past, most studies on falls have addressed children, disabled persons, or the very elderly. There is little information on more general populations, or whether a standardized set of environmental modifications — not designed to address any specific disability — would reduce falls and their consequences.

Keall et al studied households (n = 842) in New Zealand, including persons of all ages. Subjects were identified as holders of what is called a “community services card,” which indicates that either the person is low income, unemployed, a student, over the age of 65 years, or receives governmental health benefits related to illness.

Half of the homes in the study received no intervention. The other half received home modifications, including handrails for steps and stairs (inside and out), repairs to window catches, tub and toilet grab-rails, good quality outside lighting, high-visibility slip resistant edging for outside steps, securing of carpet edges, non-slip bathmats, slip-resistant resurfacing for decks/patios, and a pamphlet on home safety. All modifications were provided free of charge by a qualified builder.

Compared to non-intervention homes (control) over the 3-year period of observation, home modification reduced falls by 26% per year and all injuries by 39% per year (both statistically significant).

The average cost of the intervention was $564 New Zealand dollars, which by current currency conversion charts is $423 U.S.

Every Other Day Tadalafil for Lower Urinary Tract Symptoms and Erectile Dysfunction

SOURCE: Choi H, et al. J Int Impot Res 2014;27:

Although the incidence of erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) both increase with age, there is an as-yet ill-explained independent association of LUTS with ED. That is, within each age decile, more severe LUTS is associated with more severe ED.

The PDE-5 inhibitor tadalafil is approved for treatment of LUTS or ED. The dose used to treat LUTS is less than the usually effective dose for ED, but men treating LUTS with low-dose tadalafil (5 mg daily) also report improvements in sexual function.

Tadalafil has the longest half-life of currently available PDE5 inhibitors: 18.5 hours. Based on this long half-life, might tadalafil provide similar symptom improvement in LUTS and ED if provided every other day?

Choi et al performed a trial in men (n = 144) with symptom scores consistent with LUTS and ED to compare 5 mg tadalafil daily vs every other day. LUTS symptoms and sexual dysfunction symptoms improved to a similar degree with both regimens. Although there were some differences in outcomes that were statistically significant in favor of the daily regimen, differences were generally small and of doubtful clinical significance. Men may achieve comparable symptom improvement for ED and LUTS using tadalafil 5 mg every other day as with everyday dosing.

Reassuring Safety Data about Incretins and CHF

SOURCE: Yu OH, et al. Diabetes Care 2015;38:

The class of medications used to treat diabetes (and obesity), known as “the incretins,” includes several DPP4 inhibitors and GLP1 agonists. These agents have achieved a favorable status in prescribing algorithms because of the combination of their low risk of hypoglycemia, impact on weight (neutral for DPP4, weight loss for GLP1), and effects on postprandial glucose attributed to glucagon blunting.

Nonetheless, analysis of the SAVOR-TIMI trial, in which a 27% increased risk of congestive heart failure (CHF) was found in persons taking saxagliptin compared to placebo, spurred concerns that incretins might worsen risk for CHF. Other trials with other DPP4 inhibitors did not find a statistically significant increased CHF risk (e.g., the EXAMINE trial with alogliptin).

Yu et al performed a nested case-control analysis of diabetic patients who received new prescriptions for antidiabetic drugs and were free of CHF at that time. They compared the incidence of CHF in patients who had been prescribed incretins vs two or more other oral agents for their diabetes.

Among a population of 57,737 diabetics, 1118 incident cases of CHF were identified. Incident CHF was not more common in persons prescribed incretins; to the contrary, there was a trend toward less CHF in incretin-treated patients (odds ratio = 0.85; confidence interval, 0.62-1.16). These data are reassuring about the safety profile of incretins in regards to CHF.