EEG guidance does not prevent delirium
Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium in older adults, researchers conducted a clinical trial of 1,232 patients age 60 and older receiving general anesthesia for major surgery. Patients were randomized to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). The primary outcome was incident delirium during post-op days 1 through 5.
Delirium during post-op days 1 to 5 occurred in 26% of patients in the guided group, compared with 23% of those in the control group. The authors conclude, “This finding does not support the use of EEG-guided anesthetic administration for this indication.”
Source: Wildes TS, Mickle AM, Ben Abdallah A, et al. Effect of electroencephalography-guided anesthetic administration on postoperative delirium among older adults undergoing major surgery: the ENGAGES randomized clinical trial. JAMA. 2019;321(5):473-483.
MAJOR VASCULAR EVENTS
Older adults also benefit from statin therapy
Statin therapy has been shown to reduce the incidence of major vascular events such as myocardial infarction and stroke in various patient populations, but little is known about their benefits in older adults. A meta-analysis of 28 randomized controlled trials of statin therapy involving 186,854 patients provides evidence that statins are also effective for older adults.
Researchers examined statin effects on major vascular events (such as major coronary events, stroke, and coronary revascularizations), cause-specific mortality, and cancer incidence among patients in several age groups: 55 or younger, 56 to 60, 61 to 65, 66 to 70, 71 to 75, and older than 75. About 8% of patients in the analysis were older than 75.
The researchers found that overall, standard statin therapy or a more intensive statin regimen produced a 21% proportional reduction in major vascular events per 1.0 mmol/L reduction in low-density lipoprotein cholesterol. A significant reduction in major vascular events was found in all age groups.
The proportional reduction in major vascular events diminished slightly with age but was not statistically significant. Among patients with preexisting vascular disease, the proportional reduction in major vascular events was similar regardless of age. Nonvascular mortality, cancer death, and cancer incidence were not affected by statin use at any age.
The researchers concluded that statin therapy significantly reduces major vascular events regardless of age. Less direct evidence of benefit exists for patients older than 75 who do not already have evidence of occlusive vascular disease, but ongoing trials will investigate this question further.
Source: Cholesterol Treatment Trialists' Collaboration. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials. Lancet. 2019;393(10170):407-415.
New drug for women at high risk for fracture
The FDA has approved Evenity (romosozumab-aqqg) to treat osteoporosis in postmenopausal women at high risk for fracture, defined as women with a history of osteoporotic fracture or multiple risk factors for fracture, and for those who have failed to respond to or cannot tolerate other osteoporosis therapies. Evenity blocks the effects of the protein sclerostin and works mainly by increasing new bone formation. One dose (210 mg) consists of two subcutaneous injections, one immediately following the other, given once a month by a healthcare professional. Because the drug's bone-forming effect lessens after 12 doses, patients should receive no more than 12 doses.
Common adverse reactions are arthralgia and headache. The product labeling warns practitioners to closely monitor patients for signs and symptoms of myocardial infarction or stroke, hypersensitivity reactions, osteonecrosis of the jaw, atypical femur fracture, and hypocalcemia. Patients should receive calcium and vitamin D supplements during therapy.
Sources: US Food & Drug Administration. FDA approves new treatment for osteoporosis in postmenopausal women at high risk of fracture. News release. April 9, 2019. Evenity (romosozumab-aqqg) injection, for subcutaneous use. Prescribing information. www.pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-com/evenity/evenity_pi_hcp_english.ashx.
Patients in recovery face health challenges
According to a recent study, about 37% of adults in recovery for alcohol or other drug (AOD) misuse experience at least one of nine health problems related to their prior AOD use: liver disease, tuberculosis, HIV/AIDS or other sexually transmitted infections, cancer, hepatitis C (HCV) infection, chronic obstructive pulmonary disease (COPD), heart disease, and diabetes. Compared with the general population, those in recovery had a higher incidence of HCV infection, COPD, heart disease, and diabetes. The research was based on a cross-sectional nationally representative survey of over 2,000 US adults who report resolving an AOD.
Although many findings were intuitive, others were surprising. For example, those who named cannabis as their primary substance did not have significantly lower rates of alcohol-related liver disease compared with those for whom alcohol was primary. The authors say their study “suggests the need for earlier and more assertive intervention to help mitigate potential AOD-induced disease burden, and underscores the call for better integration of medical and substance use disorder services.”
Source: Eddie D, Greene MC, White WL, Kelly JF. Medical burden of disease among individuals in recovery from alcohol and other drug problems in the United States. Findings from the National Recovery Survey. J Addict Med. [e-pub March 16, 2019].
TOTAL HIP ARTHROPLASTY
I.V. and oral acetaminophen equally effective
To decrease the reliance on opioids for post-op pain management, researchers studied the effectiveness of I.V. and oral acetaminophen after total hip arthroplasty (THA). In a double-blinded, randomized controlled trial, 154 patients received either I.V. or oral acetaminophen as part of a comprehensive opioid-sparing multimodal analgesia strategy following THA. Primary outcomes were pain with physical therapy on postoperative day 1 (POD 1), opioid adverse reactions on POD 1, and cumulative opioid use.
The results showed no difference in opioid adverse reactions, pain scores, or opioid use between the groups: Regardless of whether they received oral or I.V. acetaminophen, patients had low pain scores, minimal adverse opioid reactions, and limited opioid usage. Says lead author Geoffrey Westrich, MD, “At a time when healthcare costs are increasingly under the microscope, the study supports the use of oral acetaminophen, which is less costly and less invasive to administer.”
Sources: Westrich GH, Birch GA, Muskat A, et al. IV vs. oral acetaminophen as a component of multimodal analgesia after total hip arthroplasty: a randomized, blinded trial. J Arthoplast. 2019 [in press]. Hospital for Special Surgery. Study finds IV and pill form of acetaminophen work equally well after hip replacement. News release. March 12, 2019.