Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Sucampo Pharmaceuticals, Takeda, Boehringer Ingelheim; and is a consultant and on the speaker's bureau for Novo Nordisk, Lilly, Daiichi Sankyo, Forest Pharmaceuticals, Cephalon, Novartis, and Sanofi Aventis.

Helping heart failure patients feel better with iron

Source: Anker SD, et al. Ferric carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med 2009;361:2436-2448.

Globally defined, heart failure exists when delivery of oxygen to the tissues is insufficient to meet demand. Anything that compromises oxygen delivery or impairs blood oxygenation can only compound the situation. Accordingly, patients with chronic heart failure (CHF) who are anemic might understandably suffer greater symptom burden or limitations as a result.

Anker et al enrolled patients with CHF (n = 459) and iron deficiency as documented by a low ferritin level. Patients were randomized to receive either placebo or iron intravenously (as ferric carboxymaltose) and followed for 6 months. The primary outcomes of the trial were self-reported global assessment and NYHA functional class.

Iron was administered as a 4 mL bolus IV (200 mg iron) weekly until iron levels were restored (as measured by ferritin, hemoglobin, and transferrin saturation), and then monthly until the end of the trial.

At the end of the trial, both the global assessment and NYHA class were improved to a statistically significant degree more in the iron group than in the placebo group. There were no serious adverse reactions with the ferric carboxymaltose.

Previous smaller studies have generally had similarly favorable outcomes. Interestingly, both this trial and earlier trials have found that iron supplementation benefits CHF patients with or without anemia, suggesting that more study of the pathophysiologic role of iron in CHF is needed.

COPD and osteoporosis

Source: Ferguson GT, et al. Prevalence and progression of osteoporosis in patients with COPD: Results from the TOwards a Revolution in COPD Health study. Chest 2009;136:1456-1465.

Of the top 10 causes of death in America, COPD (fourth) might be likened to the Rodney Dangerfield of mortal maladies: "It don't get no respect." Our pulmonology colleagues like to remind us that in contrast to the other 9 top 10 mortal disorders — which are either improving or at least leveling off — COPD mortality is actually rising. One way to awaken clinicians' interest in COPD is to remind them that it's not just about the lungs: Patients with COPD suffer detriment in multiple tissue compartments, such as bone health.

The TORCH trial (TOwards a Revolution in COPD Health) studied inhaled fluticasone, inhaled salmeterol, both, or placebo in more than 6000 subjects. A subgroup study (n = 658) looked at the effects on bone mineral density (BMD) of each treatment arm.

At baseline, more than half of both men and women with COPD had either osteoporosis or osteopenia. Although frank osteoporosis was more common in women (30% vs 18%), osteopenia was equal. This is a critically important observation, since most fractures happen in subjects with osteopenia not osteoporosis. (This is likened to the situation in hypertension: Even though the risk of severe HTN is greater, since there are so many more folks with stage 1 or stage 2 hypertension, most of the CV burden of HTN is not shouldered by folks with severe HTN).

The good news: There was no meaningful change in BMD related to inhaled steroids (alone or in combination with salmeterol). The bad news: Osteopenia and osteoporosis are frighteningly commonplace in COPD.

Prediabetes treatment: A wealth of opportunity

Source: Rhee MK, et al. Many Americans have pre-diabetes and should be considered for metformin therapy. Diabetes Care 2010;33:49-54.

It is estimated that almost 40 million Americans have diabetes, and more than twice that many have prediabetes. Clinical trials from the United States and other nations indicate that prediabetes progresses at a rate of 6%-10% each year to frank diabetes. Fortunately, the menu of interventions that forestall development of diabetes from prediabetes continues to expand. It now includes diet, exercise, metformin, thiazolidinediones, acarbose, and orlistat.

In the recent past, it has been suggested that persons with prediabetes merit pharmacotherapy with metformin (in addition to lifestyle changes) if they have both impaired fasting glucose and impaired glucose tolerance and any one of: age > 60 years, BMI > 30 kg/m2, family history of diabetes, elevated triglycerides, reduced HDL, hypertension, or A1c > 6%.

Rhee et al invited employees of the Grady Health System, Emory HealthCare and University, and Morehouse School of Medicine to be screened for diabetes. Of the volunteers who qualified for glucose tolerance testing (n = 1581), the combination of factors sufficient to merit metformin treatment was 8.1%; an additional 4.6% of subjects were newly diagnosed as frankly diabetic. Now that firm indications for pharmacotherapy of prediabetes are established, clinicians have a wealth of opportunity for timely intervention.