ACV y uso de antiinflamatorios no esteroideos

Stroke risk and NSAIDs: an Australian population-based study.

Med J Aust. 2011 Nov 7 ; 195(9):525-9.

Caughey GE, Roughead EE, Pratt N, Killer G, Gilbert AL.

Source

Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute, University of South Australia, Adelaide, SA, Australia. gillian.caughey@unisa.edu.au.

Abstract

OBJECTIVE:

To determine the risk of stroke associated with non-steroidal anti-inflammatory drug (NSAID) use.

DESIGN, SETTING AND PARTICIPANTS:

Retrospective cohort study of 162 065 Australian veterans with incident dispensing of an NSAID between 1 January 2001 and 31 December 2008, using prescription event sequence symmetry analysis.

MAIN OUTCOME MEASURES:

Hospitalisation for stroke, ischaemic stroke or haemorrhagic stroke.

RESULTS:

The absolute risk of stroke was low: 7.1/1000 people/year. Incident use of NSAIDs was associated with a 1.88 times increased risk (95% CI, 1.70-2.08) of hospitalisation for stroke (ischaemic or haemorrhagic) following first ever dispensing of an NSAID. This equates to an increased absolute risk of 13.4 strokes/1000 people/year. Significant positive associations between starting an NSAID and having a hospitalisation for stroke were found for most NSAIDs, with adjusted sequence ratios ranging from 1.44 (95% CI, 1.16-1.80) for indomethacin to 1.80 (95% CI, 1.59-2.04) for rofecoxib.

CONCLUSIONS:

Incident use of NSAIDs was associated with an increased risk of stroke. Increased awareness of the potential for serious adverse cardiovascular events, together with individual assessment of cardiovascular risk, careful deliberation of the balance between risk and benefits and appropriate supervision, is required when initiating NSAID therapy.

Full Text Sources

• Australasian Medical Publishing Company

Mi comentario: devido a los EVC que se han encontrado relacionados con los AINES, cada vez tenemos que tener más cuidado en la precripción de éstos fármacos en nuestros pacientes, por lo que la vieja regla de individualizar a los pacientes sigue vigente, sobre todo en el uso de estos medicamentos para el manejo del dolor crónico, tratando de usarlos por el más corto perído de tiempo y en pacientes sin riesgo cardiovascular y sobre todo tener mucho cuidado del uso de los mismos en hpertensos y en Adultos Mayores.

Sobre el tratamiento en DM-2

Risk of cardiovascular disease and all cause mortality among patients with type 2 diabetes prescribed oral antidiabetes drugs: retrospective cohort study using UK general practice research database


Objective To investigate the risk of incident myocardial infarction, congestive heart failure, and all cause mortality associated with prescription of oral antidiabetes drugs.

Design Retrospective cohort study.

Setting UK general practice research database, 1990-2005.

Participants 91 521 people with diabetes.

Main outcome measures Incident myocardial infarction, congestive heart failure, and all cause mortality. Person time intervals for drug treatment were categorised by drug class, excluding non-drug intervals and intervals for insulin.

Results 3588 incident cases of myocardial infarction, 6900 of congestive heart failure, and 18 548 deaths occurred. Compared with metformin, monotherapy with first or second generation sulphonylureas was associated with a significant 24% to 61% excess risk for all cause mortality (P<0.001) and second generation sulphonylureas with an 18% to 30% excess risk for congestive heart failure (P=0.01 and P<0.001). The thiazolidinediones were not associated with risk of myocardial infarction; pioglitazone was associated with a significant 31% to 39% lower risk of all cause mortality (P=0.02 to P<0.001) compared with metformin. Among the thiazolidinediones, rosiglitazone was associated with a 34% to 41% higher risk of all cause mortality (P=0.14 to P=0.01) compared with pioglitazone. A large number of potential confounders were accounted for in the study; however, the possibility of residual confounding or confounding by indication (differences in prognostic factors between drug groups) cannot be excluded.

Conclusions Our findings suggest a relatively unfavourable risk profile of sulphonylureas compared with metformin for all outcomes examined. Pioglitazone was associated with reduced all cause mortality compared with metformin. Pioglitazone also had a favourable risk profile compared with rosiglitazone; although this requires replication in other studies, it may have implications for prescribing within this class of drugs.

Bibliografía: Tzoulaki et al , BMJ 2009;339:b4731 2009

Información sobre Sitagliptina

Información para los profesionales de la salud
La pancreatitis aguda y la sitagliptina (Januvia y comercializado como Janumet)
[09/25/2009]La FDA está revisando la información de prescripción de Januvia (sitagliptina) y Janumet (sitagliptina / metformina) para incluir información sobre casos de pancreatitis aguda en pacientes que utilizan estos productos.
La sitagliptina, el primero de una nueva clase de fármacos se denominan inhibidores de la diabetes-4 (DPP-4) los inhibidores, está aprobado como adyuvante de la dieta y el ejercicio para mejorar el control glucémico en adultos con diabetes mellitus tipo 2.
Ochenta y ocho casos de post-comercialización de la pancreatitis aguda, incluyendo dos casos de pancreatitis hemorrágica o necrotizante en pacientes tratados con sitagliptina, se informó a la Agencia entre 16 de octubre 2006 y 9 de febrero de 2009. Basándose en estos informes, la FDA está trabajando con el fabricante de la sitagliptina y la sitagliptina / metformina para revisar la información de prescripción para incluir:
La información relativa a los informes posteriores a la comercialización de la pancreatitis aguda, incluyendo las formas graves, pancreatitis hemorrágica o necrotizante.
La recomendación de que los profesionales sanitarios vigilar a los pacientes cuidadosamente para el desarrollo de pancreatitis después de la iniciación o aumento de la dosis de sitagliptina o sitagliptina / metformina, así como dejar de sitagliptina o sitagliptina / metformina, si se sospecha de pancreatitis durante el uso de estos productos.
Informaciones que dan cuenta que la sitagliptina no se ha estudiado en pacientes con antecedentes de pancreatitis. Por lo tanto, no se sabe si estos pacientes tienen un mayor riesgo de desarrollar pancreatitis durante el uso de sitagliptina o sitagliptina / metformina. La sitagliptina o sitagliptina / metformina debe utilizarse con precaución y con un seguimiento adecuado en pacientes con antecedentes de pancreatitis.
Esta información refleja el análisis actual de la FDA de los datos a disposición de la FDA en relación con este fármaco. La FDA tiene la intención de actualizar esta hoja cuando la información adicional o de los análisis estén disponibles.
Para reportar efectos adversos inesperados o graves asociados con el uso de este medicamento, póngase en contacto con el programa de la FDA MedWatch y completar un formulario con la información en la parte inferior de la página.
Consideraciones para Profesionales de la salud:
- Sea consciente de la posibilidad de controlar la aparición de los signos y síntomas de pancreatitis, tales como náuseas, vómitos, anorexia y dolor abdominal persistente grave, a veces se irradia a la espalda.
- Omitir sitagliptina o sitagliptina / metformina, si se sospecha de pancreatitis.
- Entender que si se sospecha de pancreatitis en un paciente, la atención médica de apoyo debe ser instituido. El paciente debe ser estrechamente monitoreados con estudios de laboratorio adecuados, como la amilasa en suero y orina, relación amilasa / aclaramiento de creatinina, electrolitos, calcio en suero, glucosa, y la lipasa.
- Informar a los pacientes de los signos y síntomas de pancreatitis aguda para que sean conscientes y capaces de notificar a su médico si experimentan cualquier signo o síntoma inusual.
Información para los pacientes:
- Tenga en cuenta que la pancreatitis aguda ha sido reportada en pacientes tratados con sitagliptina o sitagliptina / metformina.
- Preste mucha atención a los signos o síntomas de pancreatitis, tales como náuseas, vómitos, anorexia y dolor abdominal persistente grave, a veces se irradia a la espalda.
- Examinar rápidamente los signos y síntomas de pancreatitis con un profesional sanitario.
- No dejar o cambiar los medicamentos que se han prescrito, sin antes consultar con un médico con conocimientos profesionales.
Antecedentes y resumen de datos:
La FDA ha completado una revisión de 88 casos de pancreatitis aguda en pacientes tratados con sitagliptina o sitagliptina / metformina. Los casos fueron reportados a las reacciones adversas de la FDA Event Reporting System (AERS) entre octubre de 2006 y febrero de 2009. La hospitalización se informó en 58/88 (66%) de los pacientes, 4 de los cuales fueron admitidos en la unidad de cuidados intensivos (UCI). Dos casos de pancreatitis hemorrágica o necrotizante fueron identificados en la revisión y ambos requirieron una estancia prolongada en el hospital con tratamiento médico en la UCI. Los eventos adversos más comunes informados en los 88 casos fueron dolor abdominal, náuseas y vómitos.
Además, el análisis encontró que 19 de los 88 casos (21%) de pancreatitis un plazo de 30 días de comenzar la sitagliptina o sitagliptina / metformina. Además, 47 de los 88 casos (53%) resolvió de una vez se suspendió la sitagliptina. Es importante observar que 45 casos (51%) se asociaron con al menos un factor de riesgo de desarrollar pancreatitis, tales como la diabetes, la obesidad, el colesterol alto y / o triglicéridos elevados.
Sobre la base de la relación temporal de iniciar la sitagliptina o sitagliptina / metformina y el desarrollo de la pancreatitis aguda en los casos examinados, la FDA cree que puede haber una asociación entre estos eventos. Debido a que la pancreatitis aguda se asocia con una considerable morbilidad y mortalidad, y la detección temprana es importante para reducir los resultados adversos para la salud, la FDA recomienda revisiones de la información de prescripción para alertar a los profesionales de la salud para el evento de este adversas potencialmente graves.

Seguimos con la Influenza A H1 N1

Con el enfriamiento del hemisferio Norte esperamos un repunte de la epidemia de influenza A H1 N1, por lo que los siguientes datos publicados por el Colegio Americano de Médicos en el ACP Internist Weekly del 6 de Octubre del 2009, son muy útiles e interesantes. Además contien enlaces para profundizar sobre los temas que incluye.
Influenza: masks, bacteria and vaccination effectiveness
A comparison of surgical masks and N95 respirators, reports of bacterial co-infections, and evaluations of the effectiveness of widespread vaccination were among the top news about influenza last week.
Surgical masks were about as effective as N95 respirators in preventing influenza infection among health care workers in a recent randomized trial. More than 400 nurses in eight Ontario hospitals were assigned to wear either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season. Influenza infection was measured by polymerase chain reaction or a fourfold rise in hemagglutinin titers. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and 48 (22.9%) in the respirator group, an absolute risk difference of -0.73% (P=0.86). The results were published online Oct. 1 by the Journal of the American Medical Association.
The level of protection provided by the two kinds of masks appears to be similar in routine health care settings, although the results cannot be generalized to higher-risk procedures producing aerosolization, the study authors concluded. Current CDC recommendations call for N95 respirators for all health care worker contacts with influenza patients, although the agency is now reviewing its guidelines. According to an accompanying editorial, the JAMA study will likely not resolve debate on the issue, and should not distract from other means to prevent influenza spread in health care facilities, including hand hygiene, staying home from work when sick and vaccination of health care workers.
Vaccination against pneumococcus could play a role in reducing mortality from H1N1 influenza, according to the CDC's Morbidity and Mortality Weekly Report. An analysis of specimens from 77 patients who died of the pandemic strain this summer revealed that 22 of them (29%) had concurrent bacterial infections. Ten of the patients had pneumococcus. In addition to highlighting the benefits of vaccination, the findings underscore the importance of managing influenza patients who might also have bacterial pneumonia with both empiric antibacterial therapy and antiviral medications, the CDC said. The agency also released a 2009-2010 Influenza Season Triage Algorithm to assist physicians and those under their supervision in identifying indicators of and responses to symptoms of influenza-like illness in adults.
In the latest issue of Annals of Internal Medicine, researchers used mathematical models of New York City to forecast the effectiveness and cost-effectiveness of vaccination against the current H1N1 outbreak as well as a hypothetical pandemic of H5N1. In the case of an H5N1 pandemic, they concluded that expanded use of an adjuvanted vaccine would be worthwhile. As for the current influenza, the study concluded that vaccination would be effective in shortening the pandemic if about 40% of the population could be vaccinated in November, although the results would depend on when the epidemic peaks.

Carcinoma hepatocelular y tratamientos de Diabetes Mellitus

Antidiabetic therapy and increased risk of hepatocellular carcinoma in chronic liver disease.
Donadon V, Balbi M, Ghersetti M, Grazioli S, Perciaccante A, Della Valentina G, Gardenal R, Dal Mas M, Casarin P, Zanette G, Miranda C.Department of Medicine, Internal Medicine 3rd, Pordeno
World J Gastroenterol. 2009 May 28;15(20):2506-11ne Hospital, Pordenone, Italy. valter.donadon@aopn.fvg.it


AIM: To explore the association between hepatocellular carcinoma (HCC) and type 2 diabetes mellitus, describe the temporal relations between the onset of diabetes and the development of HCC and evaluate the possible effects of antidiabetic therapy on HCC risk.

METHODS: We recruited 465 HCC patients, 618 with cirrhosis and 490 control subjects. We evaluated the odds ratio (OR) for HCC by univariate and multivariate analysis. Moreover, OR for HCC in diabetic subjects treated with insulin or sulphanylureas and with metformin were calculated.

RESULTS: The prevalence of diabetes mellitus was 31.2% in HCC, 23.3% in cirrhotic patients and 12.7% in the Control group. By univariate and multivariate analysis, the OR for HCC in diabetic patients were respectively 3.12 (CI 2.2-4.4, P < p =" 0.01)." p =" 0.007)" p =" 0.006)">

CONCLUSION: Our study confirms that type 2 diabetes mellitus is an independent risk factor for HCC and pre-exists in the majority of HCC patients. Moreover, in male patients with type 2 diabetes mellitus, our data shows a direct association of HCC with insulin and sulphanylureas treatment and an inverse relationship with metformin therapy.

Otros beneficios del café

Consumo de café y Riesgo de cáncer oral, faríngeo y de esófago en Japón
The Miyagi Cohort Study
Toru Naganuma, Shinichi Kuriyama, Masako Kakizaki, Toshimasa Sone, Naoki Nakaya, Kaori Ohmori-Matsuda, Yoshikazu Nishino, Akira Fukao and Ichiro Tsuji
American Journal of Epidemiology 2008 168(12):1425-1432
El beber café reduce el riesgo de desarrollar cáncer de la cavidad oral o garganta, por lo menos en la población general en Japón, según los resultados del estudio poblacional llamado Niyagi Cohort Study de la Tohogu University en Sendaí que se efectuó para analizar el efecto protector del mismo.
El estudio consideró datos sobre la alimentación, incluido el consumo de café.
Entre los más de 38.000 participantes, de entre 40 y 64 años, sin antecedentes de cáncer, se registraron 157 casos de cáncer de boca, faringe y esófago en los 13 años de control.
A diferencia de las personas que no consumían café, las que ingerían una o más tazas por día tenían la mitad de riesgo de desarrollar esos cánceres. Además destacaron que la reducción del riesgo incluyó a personas que tenían alta probabilidad de sufrir esos cánceres, como los bebedores o fumadores al inicio del estudio.
El equipo concluyó en su artículo que "aunque la cesación del consumo de alcohol y cigarrillos sea el mejor camino conocido para reducir el riesgo de desarrollar esos cánceres, el café podría ser un factor preventivo en poblaciones de bajo y alto riesgo".

Recomendaciones del Colegio América de Médicos (ACP) para el tratamiento de la osteoporosis:

Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians
Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Paul Shekelle, MD, PhD; Robert Hopkins, Jr., MD; Mary Ann Forciea, MD; and Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*
16 September 2008 Volume 149 Issue 6 Pages 404-415
Description: The American College of Physicians (ACP) developed this guideline to present the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis.
Methods: Published literature on this topic was identified by using MEDLINE (1966 to December 2006), the ACP Journal Club database, the Cochrane Central Register of Controlled Trials (no date limits), the Cochrane Database of Systematic Reviews (no date limits), Web sites of the United Kingdom National Institute of Health and Clinical Excellence (no date limits), and the United Kingdom Health Technology Assessment Program (January 1998 to December 2006). Searches were limited to English-language publications and human studies. Keywords for search included terms for osteoporosis, osteopenia, low bone density, and the drugs listed in the key questions. This guideline grades the evidence and recommendations according to the ACP's clinical practice guidelines grading system.
Recommendation 1: ACP recommends that clinicians offer pharmacologic treatment to men and women who have known osteoporosis and to those who have experienced fragility fractures (Grade: strong recommendation; high-quality evidence).
Recommendation 2: ACP recommends that clinicians consider pharmacologic treatment for men and women who are at risk for developing osteoporosis (Grade: weak recommendation; moderate-quality evidence).
Recommendation 3: ACP recommends that clinicians choose among pharmacologic treatment options for osteoporosis in men and women on the basis of an assessment of risk and benefits in individual patients (Grade: strong recommendation; moderate-quality evidence).
Recommendation 4: ACP recommends further research to evaluate treatment of osteoporosis in men and women.
Recomendaciones del Colegio América de Médicos (ACP) para el tratamiento de la osteoporosis:
Recomendación Número 1: El ACP recomienda a los médicos clínicos ofrecer tratamiento farmacológico a hombres y mujeres con diagnóstico conocido de osteoporosis o que tuvieron fracturas por fragilidad. (Grado de recomendación: fuerte y Evidencia de alta calidad).
Recomendación Número 2: El ACP recomienda a los médicos clínicos considerar el tratamiento farmacológico para los hombres y las mujeres que tienen riesgo de desarrollar osteoporosis. (Grado de evidencia débil y recomendación de calidad moderada).
Recomendación Número 3: El ACP recomienda elegir el tratamiento adecuado, según los riesgos y beneficios de cada paciente. (Grado de recomendación fuerte y calidad de evidencia moderada).
Recomendación Número 4: El ACP recomienda realizar más investigaciones que evalúen el tratamiento de la osteoporosis en hombres y mujeres. Además, sostiene que es necesario buscar estrategias de prevención e investigar sobre la duración apropiada del tratamiento.
Fuente.Qaseem A, et al. Pharmacologic treatment of Low Bone Density or Osteoporosis to prevent Fractures: A clinical Practice Guideline from the American College of Physicians

Neumonía y servicios médicos

La neumonía vinculada con los servicios médicos suele ser más letal
( Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia )
Mario Venditti, MD; Marco Falcone, MD; Salvatore Corrao, MD; Giuseppe Licata, MD; Pietro Serra, MD; and the Study Group of the Italian Society of Internal Medicine* Annals 2009 150: I-36. 6 January 2009 Volume 150 Issue 1 Pages 19-26.
En este estudio publicado en Anales de Medicina Interna y conducido por médicos italianos de la Universidad de Roma, se ha encontrado que la gravedad y mortalidad de la neumonía provocada por el contacto con un paciente ambulatorio en un centro de asistencia médica es mayor que la generada por la enfermedad adquirida en la comunidad. Se encontró en el estudio que los peores resultados se encontraron con el tratamiento inadecuado de antibióticos.
Los resultados del estudio revelan que comparando los resultados de 362 pacientes tratados en 55 hospitales durante el 2007 por neumonía adquirida en la comunidad, el hospital u otro establecimiento de asistencia médica, la neumonía asociada con la atención médica ambulatoria fue más severa, requirió más días de hospitalización y las tasas de mortalidad fueron más elevadas (un 17,8 frente a un 6,7 por ciento). La tasa de mortalidad de la neumonía adquirida en el hospital fue aún mayor, siendo del 18,4 por ciento.
Dentro de la investigación se encontró además, que menos del 30 por ciento de los pacientes con neumonía asociada con la asistencia médica recibían los antibióticos recomendados, comparado con el 60 o 70 por ciento de los otros pacientes.
Por otro lado, se encontró, que para mejorar los resultados de la neumonía vinculada a la atención médica, se aconseja que la terapia con antibióticos pueda combatir el Staphylococcus aureus resistente a la meticilina o SARM y otros organismos resistentes a múltiples fármacos.
Para quién quiera leer el artículo completo, lo encontrarán a continuación
Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia
Mario Venditti, MD; Marco Falcone, MD; Salvatore Corrao, MD; Giuseppe Licata, MD; Pietro Serra, MD; and the Study Group of the Italian Society of Internal Medicine* 6 January 2009 Volume 150 Issue 1 Pages 19-26
Background: Traditionally, pneumonia has been classified as either community- or hospital-acquired. Although only limited data are available, health care–associated pneumonia has been recently proposed as a new category of respiratory infection. "Health care–associated pneumonia" refers to pneumonia in patients who have recently been hospitalized, had hemodialysis, or received intravenous chemotherapy or reside in a nursing home or long-term care facility. Objective: To ascertain the epidemiology and outcome of community-acquired, health care–associated, and hospital-acquired pneumonia in adults hospitalized in internal medicine wards. Design: Multicenter, prospective observational study. Setting: 55 hospitals in Italy comprising 1941 beds. Patients: 362 patients hospitalized with pneumonia during two 1-week surveillance periods. Measurements: Cases of radiologically and clinically assessed pneumonia were classified as community-acquired, health care–associated, or hospital-acquired and rates were compared. Results: Of the 362 patients, 61.6% had community-acquired pneumonia, 24.9% had health care–associated pneumonia, and 13.5% had hospital-acquired pneumonia. Patients with health care–associated pneumonia had higher mean Sequential Organ Failure Assessment scores than did those with community-acquired pneumonia (3.0 vs. 2.0), were more frequently malnourished (11.1% vs. 4.5%, and had more frequent bilateral (34.4% vs. 19.7%) and multilobar (27.8% vs. 21.5%) involvement on a chest radiograph. Patients with health care–associated pneumonia also had higher fatality rates (17.8% [CI, 10.6% to 24.9%] vs. 6.7% [CI, 2.9% to 10.5%]) and longer mean hospital stay (18.7 days [CI, 15.9 to 21.5 days] vs. 14.7 days [CI, 13.4 to 15.9 days]). Logistic regression analysis revealed that depression of consciousness (odds ratio [OR], 3.2 [CI, 1.06 to 9.8]), leukopenia (OR, 6.2 [CI, 1.01 to 37.6]), and receipt of empirical antibiotic therapy not recommended by international guidelines (OR, 6.4 [CI, 2.3 to 17.6]) were independently associated with increased intrahospital mortality. Limitations: The number of patients with health care–associated pneumonia was relatively small. Microbiological investigations were not always homogeneous. The study included only patients with pneumonia that required hospitalization; results may not apply to patients treated as outpatients.
Conclusion: Health care–associated pneumonia should be considered a distinct subset of pneumonia associated with more severe disease, longer hospital stay, and higher mortality rates. Physicians should differentiate between patients with health care–associated pneumonia and those with community-acquired pneumonia and provide more appropriate initial antibiotic therapy.