Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.

Food Allergy in IBS: Patch Testing

Source: Stierstorfer MB, et al. Food patch testing for irritable bowel syndrome. J Am Acad Dermatol 2013;68: 377-384.

We have, as yet, no fully satisfactory etiologic explanation for the symptom complex recognized as irritable bowel syndrome (IBS). Yet, demonstration of various derangements — hypersensitivity to neurogenic stimuli, altered bowel flora, dysregulation of serotonin — has been seen in subgroups of persons with typical IBS. Results from IBS trials of non-systemic antibiotics (e.g., rifaximin) demonstrate improvements in IBS symptoms and support bacterial flora imbalance in some, but not all, IBS subjects.

IBS patients commonly report foods that exacerbate symptoms. Could these food sensitivities represent actual food allergy, and contribute etiologically to IBS? A variety of commonplace foods and food additives have been documented to cause allergic cutaneous contact dermatitis (type-4 hypersensitivity). Could similar responses lead to inflammatory changes in the gut and symptoms of IBS?

Stierstorfer et al performed patch testing in IBS subjects (n = 51) using up to 40 different foods or food additives that have been previously recognized as implicated in food hypersensitivity. Fifty-eight percent of subjects had one or more patch test results indicating possible food sensitivity, and when the “offending” food was eliminated from the diet, about two-thirds of subjects reported symptomatic improvement. Food allergy may play a more important role in IBS than previously recognized.


A Relationship Between Atrial Flutter and Sleep Apnea

Source: Bazan V, et al. Obstructive sleep apnea in patients with typical atrial flutter: Prevalence and impact on arrhythmia control outcome. Chest 2013;143:1277-1283.

Commonly recognized consequences of obstructive sleep apnea (OSA) include increased risk for hypertension, cardiovascular events, and arrhythmias, the most common of which is atrial fibrillation (AFib). Less well understood is the relationship between atrial flutter (AF) and OSA. Even though invasive treatment through catheter ablation is highly effective for AF, over the long term, as many as one-third of AF ablation patients develop postoperative AFib, which of course has its own toxicities.

Bazan et al evaluated a preoperative population of AF patients with polysomnography, none of whom had previously been diagnosed with or suspected of OSA. Overall, 82% of subjects were diagnosed with OSA, almost half of whom were graded as severe OSA.

Over the ensuing 12 months, use of continuous positive airway pressure (CPAP) in OSA patients who had received catheter ablation for AF resulted in a dramatic reduction in new postoperative AFib: from 46% (untreated) to 6% (treated).

OSA appears to be more commonplace in AF than previously recognized. Although a much larger randomized clinical trial will be necessary for confirmation, this small study suggests that for AF patients with OSA who are undergoing catheter ablation, CPAP substantially reduces the likelihood of postoperative AFib.


Beyond Hypertension: Metabolic Effects of Telmisartan

Source: Takagi H, et al. Telmisartan as a metabolic sartan: The first meta-analysis of randomized controlled trials in metabolic syndrome. J Am Soc Hypertens 2013;7:229-235.

It has not gone unnoticed that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ARBs) can sometimes have a favorable effect on glucose metabolism in diabetics and prediabetics. Experts have opined that it is perhaps vascular dilation in the skeletal muscle compartment from renin-angiotensin-aldosterone system blockade that produces increased glucose utilization. One of the ARBs, telmisartan, in addition to its blood pressure-lowering effect, has been noted to have peroxisome proliferator-activated receptor (PPAR)-gamma activation activity, distinct from the other members of this drug class. PPAR-gamma activation could favorably impact metabolic syndrome, but individual clinical trials of telmisartan have been inconclusive in this regard.

Takagi et al performed a meta-analysis of clinical trials (n = 10) of telmisartan in patients (n = 546) with metabolic syndrome. Favorable effects were seen for fasting glucose, insulin, and A1c. Of the 10 trials analyzed, only three included data on adiponectin, but results were also favorable for this metric.

Large clinical trials of telmisartan in patients with established vascular disease (e.g., TRANSCEND, n = 5926) have shown a nonsignificant trend toward less new onset diabetes, but the number of metabolic syndrome subjects in this trial was not specified.

Whether favorable changes seen in metabolic syndrome patients treated with telmisartan are sufficient to improve “hard” outcomes (myocardial infarction, cerebral vascular accident, diabetes mellitus) would require a very large clinical trial.