Clinical Briefs

By Louis Kuritzky, MD

Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Abbott, AstraZeneca, Boehringer Ingelheim, Daiichi, Sankyo, Forest Pharmaceuticals, Lilly, Novo Nordisk, Takeda.

Once weekly exenatide vs sitagliptin or pioglitazone for type 2 diabetes

Source: Bergenstal RM, et al. Efficacy and safety of exenatide once weekly versus sitagliptin or pioglitazone as an adjunct to metformin for treatment of type 2 diabetes (DURATION-2): A randomised trial. Lancet 2010; 376:431-439.

The incretin class of medications (exenatide, liraglutide, sitagliptin, saxagliptin) all share the favorable quality of not being associated with weight gain. Recently published data support the efficacy, tolerability, and simplicity of once-weekly exenatide. Bergenstal et al compared exenatide once weekly (EXEN-W) with sitagliptin (STG) or pioglitazone (PIO) as add-on therapy for persons with type 2 diabetes (n = 491) who had not attained goal with metformin.

At the end of 26 weeks, several outcomes favored EXEN-W. A1c on EXEN-W was 0.6% lower than STG, and 0.3% lower than PIO. Weight loss was also greatest in the EXEN-W group. Adverse effect profiles with each treatment arm were consistent with prior trials, and the discontinuation rate was similar for each group.

EXEN-W reduced systolic BP more than sitagliptin, but similarly to pioglitazone. Favorable lipid effects were seen with each treatment arm: The greatest increase in HDL was seen with pioglitazone.

As clinicians make their therapeutic choices for diabetes management, the relevance of medication impact upon CV risk factors such as BP, weight, and lipids merits our consideration.

Prevalence of hearing loss in U.S. adolescents

Source: Shargorodsky J, et al. Change in prevalence of hearing loss in U.S. adolescent. JAMA 2010;304:772-778.

My grandmother always claimed that listening to loud rock and roll music would be the demise of my hearing ... but I still don't know if she was right. In those days we used to listen to something called a record player (younger clinicians interested to see such an archaic device can readily locate one on Google), and I have always wondered whether those cars bouncing up and down at the traffic light next to me, loaded with rap music, would be determined to be similarly ototoxic, or worse. Well, if the NHANES data are correct, we still don't know.

According to this analysis of data from NHANES, the prevalence of hearing loss has increased when one compares the 1988-1994 interval with 2005-2006. Indeed, the relative risk of any hearing loss (induced by any factor) has increased by more than 30%.

Hearing loss was associated with poverty and a history of > 3 ear infections, but not exposure to persistent (> 5 hrs/week) loud noise or firearm use. In support of grandma's point of view, a recent study from Australia noted hearing loss 70% more often in teens who had used personal stereo devices.

Overall, the prevalence of any hear- ing loss increased from 11.1% to 14.0% over the decade studied; further elucidation of modifiable risk factors would be helpful.

Postoperative abdominal wall hernias: Best repair methodology

Source: Itani KM, et al. What to advise patients about hernias. Arch Surg 2010;145:322-328.

The literature indicates that almost one-fourth of persons who undergo abdominal surgery will subsequently incur an abdominal wall hernia. The optimum method for repairing such hernias has not been established. Itani et al performed a randomized trial of laparoscopic vs open repair of ventral incisional hernias at four Veterans Affairs hospitals (n = 162).

There was a substantial risk reduction for complications in the laparoscopic group vs the open repair group (absolute incidence = 31.5% vs 47.9%). In particular, surgical wound site infection was almost 4-fold less in the laparoscopic group. Pain scores at 1 year were less in the laparoscopic group, and return to work was quicker. The only major advantage of open surgical treatment was the incidence of major complications, primarily bowel injury (4.4% in the laparoscopic group vs 1.4% in the open surgery group). One additional advantage of open surgical repair was a trend toward lower recurrence in this group (8.2% vs 12.5%; P = NS).

In general, asymptomatic incisional ventral hernias do not require repair, but once they are symptomatic, laparoscopic surgery shows distinct advantages. The surgeons in this trial had not performed a high volume of laparoscopic procedures; hence, clinicians might anticipate even better outcomes as experience accrues.