Clinical Briefs

By Louis Kuritzky, MD

Prevention of Cardiovascular Events with Low-Dose Aspirin and Vitamin in Type 2 Diabetic Patients

Pooled data (n = 50,000) on primary prevention of cardiovascular disease with aspirin (ASA) indicates as much as 28% reduction in coronary heart disease, albeit no demonstrable effects upon total mortality or stroke. Recent data from the Primary Prevention Project, a large scale trial of persons with known cardiovascular risk factors (n = 4495) have corroborated that low-dose ASA provides a 40% or greater risk reduction for cardiovascular death.

The benefits of primary prevention with ASA specifically in diabetics remains less certain though meta-analysis suggests substantially lower benefits for diabetics afforded by primary prevention (7%) than we have seen demonstrated for secondary prevention (25%).

Sacco and colleagues report on the diabetic cohort of the Primary Prevention Project trial (n = 1031) who were randomly assigned to low-dose ASA (100 mg/d) and vitamin E. Consonant with recently published major clinical trials (HOPE, Heart Protection Study), no perceptible benefit from vitamin E was found. Disappointingly, no statistically significant benefits of ASA in this diabetic population could be confirmed, as far as cardiovascular death, stroke, or MI (composite end point) or total cardiovascular events. Indeed, there was a trend toward increased cardiovascular deaths. It is postulated that non-platelet-related vasculopathic forces in diabetic patients may counterbalance beneficial platelet effects of ASA.

Sacco M, et al. Diabetes Care. 2003;26:3264-3272.

Cinnamon Improves Glucose and Lipids of People with Type 2 Diabetes

There is a strong connection between diet and diabetes, but "best diet" remains elusive. Choosing foods with favorable glycemic index (lesser rate of rise of glucose) has been shown to positively effect diabetic control. Some spices, for instance bay leaves, cinnamon, cloves, and turmeric have been noted improve insulin sensitivity in vitro.

Animal studies have provided intellectual fodder for a putative role of cinnamon (CINN) in enhanced insulin activity, favorably affecting glucose uptake, glycogen synthesis, and insulin receptor phosphorylation. The effects of CINN supplementation in humans has been heretofore unknown. Finely ground CINN mixed with flour was packaged into 500 mg capsules and administered in doses of 1 g, 3 g, or 6 g daily for 60 days. Subjects continued their regular diet (and medication) otherwise unaltered.

CINN produced an 18-29% decrease in fasting glucose levels at 60 days, but no dose-response curve was seen (ie, all doses reduced glucose to a similarly favorable degree). Comparable reductions in total cholesterol (13-26%) and LDL cholesterol (10-24%) were also demonstrated. Favorable effects were seen at CINN ingestion levels from 1-6 g/d. Whether even lower levels might be beneficial remains to be determined.

Khan A, et al. Diabetes Care. 2003;26:3215-3218.

Depression Care on Pain and Functional Outcomes Among Adults with Arthritis

Arthritis is the most commonplace cause of disability in the United States, with as many as one-third of persons older than age 65 manifesting osteoarthritis (OA) of the knee. It is not uncommon for this same population to suffer comorbid depression, magnifying dysfunction associated with OA. No previous trial has examined the impact of depression treatment upon pain or functional outcome in OA.

The population studied comprised subjects with both knee OA and non-suicidal unipolar depression (n = 1801). Patients were randomized to "usual care" or a program of antidepressant pharmacotherapy and 6-8 psychotherapy sessions. OA pain intensity and its interference with daily activities were statistically significantly improved in the active treatment group. Scores on the Hopkins Symptom Checklist were much more likely to improve among intervention recipients than "usual care" (41% vs 18%).

Specifics about individual pharmacotherapies are not included in the study, for instance, we do not know which specific antidepressant agents were used. Antidepressants with norepinephrine reuptake inhibition activity have already demonstrated favorable effects in some pain syndromes. At any rate, successfully addressing depression in persons suffering pain from OA with counseling and pharmacotherapy has been shown to reduce OA-related morbidity.

Lin EB, et al. JAMA. 2003;290: 2428-2434.

Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.