Consequences of NSAID Use in Patients Receiving Post-MI Antithrombotic Prophylaxis

SOURCE: Olsen AMS, et al. JAMA 2015;313:805-814.

Most patients receive antiplatelet treatment after an acute coronary syndrome. Combinations of antiplatelet agents (e.g., ASA, clopidogrel) reduce risk of recurrent MI — particularly stent thrombosis — but do have a modest increase in bleeding risk. Well, what about our post-MI patients who are taking appropriately prescribed antiplatelet agents who also require treatment with NSAIDs for disorders like osteoarthritis, migraine, etc? How does such multidrug co-administration affect risks?

Olsen et al recently published results from data collected through Danish nationwide administrative registries that assessed bleeding events and cardiovascular events based on prescription data from 62,971 adults. The cohort evaluated included adults over age 30 (mean age = 68 years) who were admitted for a first MI in the 2002-2011 interval.

Rates of bleeding were doubled when NSAID users (that is, NSAIDS + antithrombotic treatment) were compared with non-users (that is, antithrombotic treatment alone). Equally concerning, the hazard ratio for cardiovascular (CV) events was 40% greater in NSAID users than non-users, irrespective of particular type of NSAID prescribed or duration of use.

This report should prompt clinician vigilance in post-MI patients taking antithrombotic therapy to limit the use of NSAIDs to the minimum necessary.

Psoriasis Is Associated with Insulin Resistance

SOURCE: Gyldenlove M, et al. J Am Acad Dermatol 2015;72:599-605.

The pathophysiology of psoriasis has much in common with rheumatoid arthritis (RA). Recently, pharmacotherapies that had been primarily used in RA have enjoyed successful application in psoriasis, leading to marked improvements or even remission. Of concern, both RA and psoriasis have been recognized as risk factors for cardiovascular disease. Psoriasis is also a risk factor for diabetes, but the mechanism remains ill-defined.

A consistent finding in patients with type 2 diabetes is the presence of insulin resistance, usually associated with obesity. Might psoriasis also be associated with insulin resistance, independent of obesity? To answer this question, Gyldenlove et al compared psoriatic patients with controls of similar age (mean = 44 years) and BMI (mean = 26, [overweight]), all of whom had undergone laboratory screening (fasting glucose and A1c) to exclude undiagnosed diabetes.

Insulin sensitivity was substantially reduced in patients with moderate-to-severe psoriasis compared to controls, even though there was no manifest glucose intolerance. Hence, psoriasis might be considered a pre-diabetic state.

Difficult Questions About Testosterone and Mortality

SOURCE: Eisenberg ML, et al. Int J Impot Res 2014;27:46-48.

The number of men receiving treatment for hypogonadism has increased dramatically over the past decade. At the same time, some clinical trials have suggested that there are safety issues with testosterone. For instance, one trial of frail seniors was stopped early because of an increased mortality signal. Other clinical trials have not demonstrated similar risk. Ultimately, the only way the question about testosterone safety can be convincingly answered is by performance of a large randomized, prospective trial, similar to the Women’s Health Initiative (WHI).

In the meantime, other trial data may inform clinician choices about testosterone replacement. For instance, Eisenberg et al published their results of a retrospective analysis of the andrology database at Baylor College of Medicine (Houston, Texas), which included 509 hypogonadal men, approximately half of whom were treated with testosterone replacement (injectable or transdermal).

In a 10-year follow-up interval, the mortality rate trended lower in men receiving testosterone replacement than controls, but the difference was not statistically significant. Although such results cannot provide a definitive answer to the question of the relationship between testosterone replacement and mortality, they are reassuring for hypogonadal men who are enjoying symptomatic improvement through testosterone replacement.