Clinical Briefs By Louis Kuritzky, MD
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Gabapentin for Chronic Cough
Source: Ryan NM, et al. Gabapentin for refractory chronic cough: A randomised, double-blind, placebo-controlled trial. Lancet 2012;380:1583-1589.
Chronic undifferentiated cough — that is, cough without any readily visible explanation such as upper respiratory infection, lower respiratory infection, pulmonary lesion, heart failure, etc. — usually turns out to be one of three entities: post-nasal drip, asthma, or acid reflux. Indeed, empirically trying meds for such maladies usually resolves the cough. Nonetheless, despite exhaustive investigation, some patients remain with cough of undetermined etiology, at which point the treatment is problematic.
It has been suggested that chronic cough might reflect a central neural sensitization process that has some pathologic similarities to neuropathic pain. Since gabapentin works well for neuropathic pain, could it also have a positive effect on chronic cough?
Ryan et al studied a population of patients with chronic cough (n = 62) in whom secondary causes (e.g., infection, reflux, asthma) had been eliminated. Study subjects were randomized to gabapentin (up to 1800 mg/d) or placebo for 10 weeks.
At the end of the trial, gabapentin improved cough-related quality of life more than placebo and was well tolerated. Considering that in neuropathic pain trials the dose of gabapentin has been up to twice as high (3600 mg/d), it is reassuring to note that moderate gabapentin doses provide clinically relevant cough improvements. In an era of closer scrutiny applied to use of opioids, another alternative for chronic undifferentiated cough is welcome.
Can Statins Reduce Cancer-Related Mortality?
Source: Nielsen SF, et al. Statin use and reduced cancer-related mortality. N Engl J Med 2012;367:1792-1802.
It is generally believed that the primary mechanism of statin-related cardiovascular (CV) risk reduction is achieved through reductions in LDL. That statins might have other pleiotropic actions, such as plaque stabilization, is the subject of much controversy. Recently, recognition of the impact of statins on new-onset diabetes (a relative 9% greater risk than non-statin users) has given reason for pause. For secondary prevention, the risk-benefit ratio is prominently positive for statin therapy, but much less convincing for primary prevention. A similar picture is emerging in reference to aspirin in CV prophylaxis.
Reminiscent of the aspirin story (i.e., even though primary prevention with aspirin has never been shown to reduce mortality, the favorable effects on CV events — when combined with recently recognized cancer risk reduction — sweetens the deal), we are presented now with the suggestion that statins also reduce cancer-related mortality.
Nielsen et al report on a large dataset of Danish patients who had a diagnosis of cancer (n = 295,925) over the 1995-2007 interval. A comparison was made between statin never users (n = 277,204) and statin users (n = 18,721) with respect to overall and cancer-related mortality.
Statin users had a 15% relative risk reduction for cancer-related death when compared to non-users. Thirteen different cancer types were specified, each of which demonstrated similar benefit. The authors suggest that the cholesterol synthesis-limiting effects of statins may disrupt cancer cell membrane stability and cellular processes, leading to the beneficial observed effects.
Are All of Those Multivitamin Dollars Well Spent?
Source: Sesso HD, et al. Multivitamins in the prevention of cardiovascular disease in men: The Physicians’ Health Study II randomized controlled trial. JAMA 2012;308:1751-1760.
Americans have been depicted as an overly pill-happy lot, much more motivated to take a statin than incorporate dietary change for cholesterol, or take a sulfonylurea rather than exercise and lose weight to improve their diabetes, etc. For a while, the idea of multivitamins seemed like a no-lose proposition; after all, few of us were keeping track of the amounts of essential nutrients we ingest, so multivitamins appeared to provide, at worst, an innocent and inexpensive nutrient insurance policy.
In an era in which essential nutrient deficiency is a stark rarity, the use of vitamin and nutrient supplements is increasingly called into question.
The Physicians’ Health Study II is a controlled trial of adult (age > 50 years) male U.S. physicians (n = 14,641) randomized to a daily multivitamin or placebo. Over a follow-up period of (median) 11.2 years, there was no discernible difference between placebo and a daily multivitamin on CV events, stroke, or mortality.
A parallel “sister study” from the Physicians’ Health Study reported a week later in JAMA had slightly more encouraging news: Within the same population as mentioned above, the risk of total cancer was reduced by 8% in multivitamin users. Although the risk reduction for cancer was small, and the P value only marginally significant, for clinicians who would advocate for multivitamins in the face of failed CV data, the cancer outcomes are modestly more sanguine.Gabapentin for Chronic Cough; Can Statins Reduce Cancer-Related Mortality?; Are All of Those Multivitamin Dollars Well Spent?
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