1. Modelling study suggests that statins may be significantly overprescribed
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1279
Editorial: http://annals.org/aim/article/doi/10.7326/M18-3066
URLs go live when the embargo lifts
A study that used a computer model to examine the benefits and harms of statins suggests that they may be overprescribed for the primary prevention of cardiovascular disease. Potential risks seem to outweigh the benefits for people whose 10-year cardiovascular disease (CVD) risk is 7.5 to 10 percent as guidelines currently recommend. Prescribing only for those at higher risk thresholds would mean that millions of people would no longer be eligible for statin therapy. The findings are published in Annals of Internal Medicine.
Currently, statins are among the most commonly prescribed drugs worldwide, with more than 30 percent of adults over the age of 40 being eligible for treatment based on current guidelines. Most guidelines recommend statins as primary prevention for people without previous cardiovascular disease when the 10-year risk for CVD exceeds 7.5 percent to 10 percent, but whether and how guideline developers weighed harms against benefits is often unclear.
Researchers from the University of Zurich evaluated the 10-year CVD risk threshold at which the benefits of statins outweighed the harms, with separate estimates for men and women across various age groups. Using an approach developed by investigators at the national Cancer Institute, the researchers projected disease-related events and drug-related adverse events (myopathy, hepatic dysfunction, and incident diabetes) over time while accounting for competing mortality. They consistently found that the harms exceeded the benefits until 10-year CVD risk thresholds were substantially higher than recommended by current guidelines. For example, among men aged 70 to 75 with no prior cardiovascular disease events, benefits of statin therapy did not outweigh harms until 10-year CVD risk was above 21 percent.
According to the author of an accompanying editorial from Yale University School of Medicine, the study authors included a wide range of adverse events for statin therapy that were largely dismissed in other guidelines. Regardless, the study may help to inform decision-making for older adults who are more concerned about the harms of treatment.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Milo Puhan, MD, PhD, please contact Felix Straumann felix.straumann@tamedia.ch.
2. Opioid epidemic causes huge spike in drug use-associated infective endocarditis
Sharp increase in hospitalizations and surgeries is straining health care resources
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2124
Editorial: http://annals.org/aim/article/doi/10.7326/M18-3026
URLs go live when the embargo lifts
Researchers have identified another epidemic stemming from the nation's opioid crisis. Hospitalizations for drug use-associated infective endocarditis (DUA-IE), a severe infection of the heart valves that can occur by injecting drugs, have increased significantly over the past decade in North Carolina and have likely increased across the entire country. Over this same time period, related heart valve surgeries have also increased. The findings are published in Annals of Internal Medicine.
Infective endocarditis can occur for numerous reasons and drug use was previously an uncommon cause of infective endocarditis in North Carolina. Now, due to the rise of opioid use and DUA-IE, the epidemiology of infective endocarditis is fundamentally changing.
Researchers at the University of North Carolina at Chapel Hill used a statewide hospital discharge database to examine hospitalization trends for DUA-IE, the proportion of hospitalizations with surgery, patient characteristics, length of stay, and charges. They found a 12-fold increase in DUA-IE and a 13-fold increase in DUA-IE hospitalizations with valve surgery. Similar increases were not seen in the comparison group, which comprised persons with endocarditis but without drug use. They also noted that the rise of DUA-IE is primarily impacting young persons and valve surgery, which results in long and costly hospitalizations (median hospital charges commonly exceed $250,000), is impacting health care costs for both insurers and hospitals.
According to the study authors, these findings suggest that resources for addressing substance use disorder are urgently needed. These include improving the infrastructure for delivering medications to treat opioid use disorder and linking patients to harm reduction services.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Asher J. Schranz, MD, please contact Mark Derewicz at Mark.Derewicz@unchealth.unc.edu.
3. Eczema more prevalent among older adults than previously thought
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2246
URLs go live when the embargo lifts
Evidence from a population-based study shows that rates of physician-diagnosed atopic eczema (also known as atopic dermatitis or simply eczema) are high among older adults. A brief research report is published in Annals of Internal Medicine.
While traditionally considered a childhood disease, increasing genetic and epidemiologic evidence suggest that eczema is an episodic, inflammatory disorder than can develop at any age. The disease affects up to 25 percent of children, but little is known about physician-diagnosed adult disease.
Researchers from the University of California, San Francisco, analyzed data from a large, population-representative database in the United Kingdom where primary care physicians manage 97 percent of eczema cases. They used a carefully validated diagnostic algorithm to estimate the age-specific prevalence of active eczema across the lifespan of this primary care population. Among 8,604,333 persons aged 0 to 99 years, the cumulative lifetime prevalence of atopic eczema was 9.9 percent and rates of active disease were highest among children and older adults. The researchers suggest that the prevalence may actually be higher than their estimates, as medical records do not capture self-treatment.
According to the authors, high rates of eczema among older adults highlight an important area for increased attention given the growing size of the elderly population.
Media Contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview someone the lead author, Katrina Abuabara, MD, please contact Elizabeth Fernandez at Elizabeth.Fernandez@UCSF.edu.
4. Liraglutide significantly reduces risk for major cardiac events in elderly patients with diabetes
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1569
URLs go live when the embargo lifts
A post-hoc analysis of data from the LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results) trial found that compared with placebo, liraglutide significantly reduced the risk for major adverse cardiovascular events in high-risk elderly patients with diabetes. Findings from a brief research report are published in Annals of Internal Medicine.
Complications associated with type 2 diabetes increase with age, making it more challenging to treat elderly patients with diabetes. The LEADER trial showed that showed a 13 percent reduction in major adverse cardiovascular events with liraglutide versus placebo. Researchers from Larner College of Medicine at the University of Vermont conducted a post hoc analysis of the trial data focusing on outcomes in elderly patients at high risk for cardiovascular events. They found that patients aged 75 or older had a 34 percent and 29 percent risk reduction in the frequency of major adverse cardiovascular events and expanded outcomes from those events, respectively, with liraglutide versus placebo. The reductions were less prominent in patients aged 60 to 74 and in those under 60. The risk-reduction in all-cause death with liraglutide was much higher in the elderly population, as well.
According to the researchers, these results should aid physicians in making clinical decisions on optimal management of type 2 diabetes in elderly patients.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview lead author, Matthew P. Gilbert, DO, MPH, please contact Alexandra Tursi at Alexandra.Tursi@uvmhealth.org.
###
Also in this issue:How Would You Manage This Patient With Gout? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Risa B. Burns, MD, MPH; C. Christopher Smith, MD; Robert H. Shmerling, MD; and Anjala Tess, MD
Annals Beyond the Guidelines
Free content: http://annals.org/aim/article/doi/10.7326/M18-2548
Ensuring Fairness in Machine Learning to Advance Health Equity
Alvin Rajkomar, MD; Michaela Hardt, PhD; Michael D. Howell, MD, MPH; Greg Corrado, PhD; Marshall H. Chin, MD, MPH
Special Article
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1990
Editorial: http://annals.org/aim/article/doi/10.7326/M18-3297
Journal
Annals of Internal Medicine