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.

Aspirin for primary prevention in diabetes? Maybe

Source: Calvin AD, et al. Aspirin for the primary prevention of cardiovascular events: A systematic review and meta-analysis comparing patients with and without diabetes. Diabetes Care 2009;32:2300-2306.

The syllogism seemed so simple: 1) The CV risk reduction of aspirin (ASA) in primary prevention is linearly related to baseline risk; 2) DM is a high-risk population for CV events; and therefore, 3) ASA should be really good for primary prevention in diabetics. Well, it's not quite so simple.

The authors of this report in Diabetes Care performed a random-effects meta-analysis and Bayesian logistic regression (whatever that means, you ask?) to provide an opinion about whether aspirin is beneficial for primary prevention in diabetes. Their conclusion, based upon 8 trials that included patients with diabetic subgroups among the overall cohort (5 trials) as well as diabetes-only trials (3 trials), is that the benefits of aspirin are similar in persons with or without diabetes.

I don't really know what "a random-effects meta-analysis and Bayesian logistic regression" means, but it would appear encouraging that this analysis, which incorporates data from 8 major clinical trials totaling more than 90,000 study subjects, suggests that aspirin might be a good thing.

Trouble is, I'm just not so sure. First, it is a matter of debate whether there is really any such thing as primary prevention in diabetes; after all, adult type 2 diabetics are considered a CV risk equivalent, since their CV risk (without ever having an MI) is as great as a person who has already had one. So, is aspirin in a diabetic primary or secondary prevention?

Secondly, the only 2 recent trials that studied only diabetics and were primarily designed to study the effects of aspirin in diabetics (the JPAD and POPADAD trials) both failed to find a beneficial effect of aspirin.

For the time being, popular opinion suggests that aspirin is a good thing. I'm not so sure.

Secondary prevention of depression: Cognitive therapy

Source:Bockting CL, et al. Long-term effects of preventive cognitive therapy in recurrent depression: A 5.5-year follow-up study. J Clin Psychiatry 2009; 70:1621-1628.

For mild-to-moderate depression, the literature indicates that cognitive therapy (COG) and pharmacotherapy have similar beneficial effects, although pharmacotherapy is often less expensive and may provide symptomatic improvement more quickly. Because depression is recurrent, it is important to identify whether long-term cognitive therapy is helpful to prevent such recurrences.

To investigate this issue, Bockting et al enrolled major depressive disorder patients who had achieved remission (n = 172) and compared usual care with usual care plus COG. The COG was administered as weekly 2-hour group sessions over a 2-month period. After this 2-month COG intervention, both groups were followed for 5.5 years.

The group that had received 8 weeks of COG had a 21% relative risk reduction for recurrence over the next 5 years. Suicide (60% of cases are related to depression) remains in the top 10 causes of death. The value of COG treatment for even as brief a period as 8 weeks might have substantial long-term clinical payoff.

Dementia: We all wish for a simple answer

Source: Snitz BE, et al. Ginkgo biloba for preventing cognitive decline in older adults: A randomized trial. JAMA 2009;302:2663-2670.

The burgeoning population of advanced seniors (age > 75 years) includes an ever-growing population of persons with cognitive impairment and dementia. Popular complementary and alternative interventions to forestall dementia abound, among which it has been suggested that ginkgo has memory-preserving qualities.

Unfortunately, the data supporting long-term favorable outcomes for cognitive function are lacking. Nonetheless, because Ginkgo biloba has a popular impression of being favorable for mental faculties, and because earlier trials have faced limitations of trial duration, size, and population age, more conclusive insights have been sought.

A study sample of community-dwelling seniors (n = 3069; mean age, 79 years) was administered either 120 mg of ginkgo or placebo twice daily for a median follow-up of 6.1 years. Rates of decline in cognitive function, and numerous other metrics including attention, language, executive function, and others, were not statistically improved by administration of ginkgo. Although there were no significant adverse effects attributable to ginkgo, there is no sound basis for advocating the use of ginkgo for long-term cognitive improvement.