by Carol A. Kemper, MD, FACP
Oregon’s Assisted Suicide Program
Source: N Engl J Med. 2003;348:961-964.
Physician-assisted suicide has been legal for terminally ill patients in Oregon since October 1997. Since then, 129 patients have chosen to participate in the program and died after ingestion of lethal medication. More than 90% died at home, and about half died in the presence of their physician. The number of patients participating in the program has steadily increased from 24 people during the first year of the program to 58 people in 2002. Interestingly, not all patients who received prescriptions for lethal medications used them. Eight patients receiving such prescriptions in 2001 and 2002 are still alive.
Of the 129 who died following ingestion of lethal medication, 79% had terminal cancer, 8% had ALS, 6% had COPD, and 7% had AIDS, scleroderma, or other heart and lung disease. Rates of physician-assisted suicide were significantly higher for patients with ALS and terminal cancer than other terminal diseases. Compared with Oregon residents who died of the same underlying disease, rates of physician-assisted suicide were higher among those who were divorced, or had higher levels of education, and they tended to be younger. These data suggest that younger, better-educated people may be more accepting of physician-assisted suicide. Although relatively few people chose to participate, the program appears to be slowly gaining in acceptance.
HIV Accelerates HCV Fibrosis
Source: Clin Infect Dis. 2003;36: 491-498.
Reports suggest that chronic hepatitis and liver disease are surpassing AIDS-related infections and malignancies as a cause of death in persons with HIV. A total of 188 patients with chronic HCV infection, including 41 with HIV coinfection, were examined for risk factors for fibrosis and cirrhosis on liver biopsy specimens. HIV-HCV coinfected patients showed significantly higher HCV viral loads, more advanced fibrosis, more frequent cirrhosis, and higher rates of fibrosis progression (the ratio of fibrosis scoring to the estimated number of years of HCV infection). An increased rate of fibrosis progression in patients with HIV-HCV coinfection was associated with higher HCV viral loads and lower CD4 counts. In contrast, the 2 most significant risk factors for progression of fibrosis in patients without HIV infection were alcohol use and older age. While lower CD4 counts clearly appeared to be a negative risk factor, the effect of HIV viral load or reconstitution of the immune system in response to antiretroviral therapy was less obvious. There was a suggestion that patients who had received a median of 36 months of highly active antiretroviral therapy and who had evidence of increased CD4 cell counts had a lower rate of fibrosis progression, although an independent effect of HAART could not be found in multivariate analysis. The lack of a statistically significant effect of either alcohol use or HAART therapy may have been a function of the smaller numbers of patients included in the analysis. Nonetheless, these data clearly demonstrates that patients with HIV-HCV coinfection, especially those with lower CD4 counts and higher HCV viral loads, are more likely to have rapid progression of fibrosis and are more likely to develop cirrhosis than people without HIV. When possible, alcohol treatment and interferon therapy should be encouraged.
Fuzeon (T-20) Goes Forward
Source: Espicom Business Intelligence. March 24, 2003.
An FDA advisory panel recently recommended FDA approval of Fuzeon (enfuvirtide), formerly known as T-20. This approval was, in part, based on the results of the TORO study soon to be published in the New England Journal of Medicine. This large-scale, nonrandomized, open-label study examined the effects of unrestricted, individually selected antiretroviral therapy with or without enfuvirtide, in heavily pretreated patients failing their current regimen (> 5000 HIV viral load). Patients had at least 6 months of prior therapy with agents in all 3 classes of antiretroviral drugs, resistance to drugs in these classes, or both. At 24 weeks of therapy, HIV viral load dropped 1.7 logs in patients receiving enfuvirtide, compared with a decrease of 0.76 logs in the control group (P < .001). CD4 cell counts increased 76 vs 32 cells/mm3 in treatment vs control subjects, respectively (P < .001). Reactions at the site of injection occurred in 98% of enfuvirtide subjects.
Dr. Kemper is Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center; Section Editor, Updates Section Editor, HIV