Ongoing drug therapy gets better results
Although therapy with buprenorphine and naloxone (referred to as buprenorphine therapy) is prescribed to treat prescription opioid addiction, healthcare providers have no evidence-based guidelines for deciding whether to taper and discontinue buprenorphine therapy or to continue prescribing ongoing maintenance therapy. To determine which approach is more effective, researchers enrolled 113 patients with prescription opioid dependence in a randomized clinical trial from February 17, 2009 to February 1, 2013. Participants were randomized to buprenorphine taper (taper condition) or ongoing buprenorphine maintenance therapy (maintenance condition). Tapering for patients in the test group started 6 weeks after patients were stabilized and lasted for 3 weeks. These participants were offered medications for opioid withdrawal, and were then offered naltrexone treatment. Participants in the maintenance group received ongoing buprenorphine therapy. All patients received drug counseling and ongoing support from nurses and healthcare providers.
Compared with the maintenance group, participants in the taper group:
- had higher levels of opioids in their urine.
- reported more days per week of opioid use (after buprenorphine was discontinued).
- had fewer consecutive weeks of opioid abstinence.
- were less likely to complete the trial.
Sixteen participants from the taper group restarted buprenorphine therapy after admitting to a relapse.
Based on these findings, researchers concluded that tapering was less effective than ongoing maintenance treatment for treating prescription opioid dependence in patients in primary care settings.
Source: Fiellin DA, Schottenfeld RS, Cutter CJ, Moore BA, Barry DT, O'Connor PG. Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial. JAMA Intern Med. [e-pub Oct. 20, 2014]
Early exposure presents long-term risks
Disturbing the “human microbiome” through use of antibiotics has been linked to the development of certain autoimmune diseases, such as rheumatoid arthritis. Previous studies have not only linked antibiotic use to the development of autoimmune diseases but have also shown that early antibiotic exposure may lead to development of irritable bowel disease in children (IBD).1 A recent study was conducted to determine whether early exposure to antibiotics increases adolescents' risk of developing juvenile idiopathic arthritis (JIA).
The study (nested, case-controlled) compared adolescents diagnosed with incident JIA before age 16, with age- and gender-matched controls. Children with prior IBD, immunodeficiency, autoimmune connective tissue disease, or vasculitis were excluded.
In total, 153 adolescents were diagnosed with JIA. Any exposure to antibiotics was associated with an increased risk of JIA and the “risk increased with the number of prescriptions in a dose-dependent manner.” Nonbacterial antimicrobial agents weren't associated with JIA. Researchers concluded that early antibiotic exposure is associated with an increased risk of JIA. “The study implicates a role for antibiotic exposure in disease pathogenesis, perhaps mediated through alteration in the microbiome.”
1. Shaw SY, Blanchard JF, Bernstein CN. Association between the use of antibiotics in the first year of life and pediatric inflammatory bowel disease. Am J Gastroenterol. 2010;105(12):2687-2692.
Source: Horton DB, Scott FI, Haynes K, et al. Antibiotic use associated with increased risk of juvenile idiopathic arthritis development. American College of Rheumatology. News release. November 11, 2014.
Two guidelines, which should be followed?
Statins are often recommended as treatment options in adults with cardiovascular disease and chronic kidney disease (CKD). However, two guidelines were released in 2013 for cholesterol management/statin treatment, and each one recommended something a little different.
- The Kidney Disease Improving Global Outcomes Lipid Work Group recommends statins for adults age 50 and older with CKD (because the risk of heart disease is increased).
- The American College of Cardiology/American Heart Association (ACC/AHA) recommends statins for adults with atherosclerotic cardiovascular disease, adults with low-density lipoprotein (LDL) cholesterol of 190 mg/dL or more, and adults age 40 to 75 with LDL cholesterol between 70 and 189 mg/dL and diabetes or a 10-year predicted risk for atherosclerotic cardiovascular disease of 7.5% or more.
To determine the “calculated agreement for statin treatment between the two guidelines for adults age 50 to 79 with CKD not on dialysis,” a study was conducted using data from the Reasons for Geographic and Racial Differences in Stroke Study. Half of the study participants with CKD (2,366 out of 4,726) were taking statins and 1,984 participants had been encouraged to take them based on the ACC/AHA's recommendations but weren't. A total of 376 participants didn't meet the criteria for statin treatment. Among these participants, the incidence of cardiovascular disease was low. Researchers concluded that “these guidelines show high concordance for statin treatments for adults with CKD.”
Sources: American Heart Association. ACC/AHA publish new guideline for management of blood cholesterol. 2013. http://newsroom.heart.org/news/acc-aha-publish-new-guideline-for-management-of-blood-cholesterol.
American Society of Nephrology (ASN). Nearly all patients with chronic kidney disease should take statins, guidelines indicate. 2014. http://www.sciencedaily.com/releases/2014/11/141113194943.htm.
Colantonio LD, Baber U, Banach M, et al. Contrasting cholesterol management guidelines for adults with CKD. J Am Soc Nephrol. [e-pub Nov. 13, 2014]
Kidney Disease Improving Global Outcomes. KDIGO clinical practice guideline for lipid management in chronic kidney disease. 2013. http://www.kdigo.org/clinical_practice_guidelines/Lipids/KDIGO%20Lipid%20Management%20Guideline%202013.pdf.
NSAID use may be problematic
To examine the relationship between use of nonsteroidal anti-inflammatory drugs (NSAIDs) and venous thromboembolism (VTE), a systematic review and meta-analysis of studies reporting risk-related data were conducted. In six studies involving 21,401 VTE incidents, the pooled risk ratio was 1.80, which led researchers to find a statistically significant increased risk of VTE among patients taking NSAIDs. They concluded that this finding “has important public health implications given the prevalence of NSAID use in the general population.”
Source: Ungprasert P, Srivali N, Wijarnpreecha K, Charoenpong P, Knight EL. Non-steroidal anti-inflammatory drugs and risk of venous thromboembolism: a systematic review and meta-analysis. Rheumatology (Oxford). [e-pub Sep. 24, 2014]