Journals watch: Colchicine for gout, CT in depression and smoking cessation

Dr Sally Hope selects the latest papers of interest to GPs including colchicine for gout, CT in treating depressionand effects of PPIs on vitamin B12,

Colchicine is one of the treatments for gout (ISTOCK)
Colchicine is one of the treatments for gout (ISTOCK)

Colchicine to prevent gout flares

Arthritis Care Res 2014; 66: 1258-62

American College of Rheumatology and European League Against Rheumatism guidelines recommend colchicine to prevent gout flares in patients initiating and increasing uric acid lowering therapy until serum uric acid is maintained at ≤6mg/dL.

In this US study of 126 patients taking colchicine for gouty flares, 73.8% of patients were deemed to be 'treated inappropriately'.

These were mainly because the patients were taking colchicine without urate-lowering therapy (allopurinol), or they had high uric acid levels with no increase in the allopurinol dose, or they had very low uric acid levels for more than a year with no flares and had not had their medication withdrawn.

Gout, which has severe systemic effects on renal function and joints, could be better managed.

However, this paper takes no account of patient preferences and some, even those with extreme gout, will not take medication.

NICE guidelines advise that to manage an acute episode, an NSAID, such as diclofenac, should be prescribed as soon as possible and continued until 48 hours after the attack resolves (a PPI or misoprostol can be coprescribed if necessary).

According to NICE, if NSAIDs are unsuitable, colchicine is an option. If colchicine is unsuitable, systemic corticosteroids can be considered.

CT in treating depression

JAMA Psychiatry 2014 doi:10.1001/jamapsychiatry.2014.1054

In this US study, 452 adults being treated as outpatients for chronic or recurrent major depressive disorder (MDD) were randomly assigned to antidepressant medication or cognitive therapy (CT) plus antidepressant medication. They were followed for 42 months and assessed blind using two evaluation rating scales.

The advantage for combined treatment was limited to patients with severe, non-chronic MDD (81.3% versus 51.7%; P =.001).

Patients in the combined group also experienced fewer serious adverse events, mainly because they spent less time on antidepressants, than the antidepressant group alone. Patients with comorbid personality disorders took longer to recover than those without.

Fewer patients dropped out of the combined treatment. The message is to initiate CT quickly for severe acute depression, as it aids recovery with antidepressant medication.

Effects of PPIs on vitamin B12

Maturitas 2014; 79: 1-2

PPIs are commonly prescribed to patients over the age of 65 years in the developed world. In some countries, they are available OTC and in others, only on prescription.

Their main indication is short term (up to eight weeks) for reflux and ulcers, but hundreds of patients are on repeat prescriptions.

Cobalamin or vitamin B12 is a tightly protein-bound water-soluble vitamin.

In the stomach, hydrochloric acid plus pepsin release cobalamin from the protein and it becomes a cobalamin-intrinsic factor complex, remaining intact until it is absorbed in the terminal ileum.

In older people, gastric acid secretion declines, so there is not enough acid to break the vitamin B12 from the protein, giving reduced absorption of vitamin B12. This hypochlohydria is exacerbated by PPIs.

This paper summarises the available evidence. Vitamin B12 deficiency is more common in patients who have been taking PPIs for two or more years.

The authors suggest that if we are initiating PPIs in patients over the age of 80, who have a higher underlying risk of developing vitamin B12 deficiency, it may be better to obtain a baseline vitamin B12 level and repeat annually if they carry on taking a PPI.

Smoking cessation in hospitals

JAMA 2014; 312(7): 719-28 doi:10.1001/jama.2014.9237

This study from the Massachusetts General Hospital in Boston, US, involved 397 smokers who said they wanted to quit while inpatients.

They all received a 'tobacco dependence intervention' in hospital and then half received automated interactive voice response telephone calls and their choice of free smoking cessation medication for up to 90 days.

The automated telephone calls promoted cessation, provided medication management and triaged smokers to receive some additional counselling.

Standard care participants received recommendations for post-discharge pharmacotherapy and counselling.

Biochemically validated seven-day tobacco abstinence at six months was higher with sustained care (26%) than with standard care (15%).

Self-reported continuous abstinence rates were 27% versus 16%.

Interest, energy and support by a medical team to help people stop smoking does work, 26% of the time.

New terminology for vulvovaginal atrophy 

Maturitas 2014 doi:1016/j.maturitas.2014.07.013

One constantly changing concern in medicine is nomenclature. 

‘Senile atrophy’, ‘vulvovaginal atrophy’ and ‘atrophic vaginitis’ are now considered inadequate to encompass the range of postmenopausal symptoms associated with estrogen deficiency in the vulva, vagina and lower urinary tract. 

Low levels of circulating estrogen after the menopause result in physiological, biological and clinical changes in the urogenital tissues. 

Anatomical changes include reduced collagen content and hyalinisation, decreased elastin, thinning of the epithelium, altered appearance and function of smooth muscle cells, increased density of connective tissue and fewer blood vessels. 

Physiological changes result in reduced vaginal blood flow, diminished lubrication, decreased flexibility and elasticity of the vaginal vault, and increased vaginal pH. Menopause-related genitourinary symptoms affect up to 50% of older women. 

The urethra and the bladder trigone are derived embryologically from the same estrogen receptor-dense primitive urogenital sinus tissue, as are the vulvar vestibule and the upper vagina. 

The new classification renames the old terms as genitourinary syndrome of menopause (GSM). Its symptoms are genital dryness, decreased lubrication with sexual activity, discomfort or pain with sexual activity, postcoital bleeding, decreased arousal, orgasm and desire, irritation/burning/itching of the vulva or vagina, dysuria and urinary frequency/urgency. 

Signs of GSM include decreased moisture and elasticity, labia minora resorption, pallor/erythema, loss of vaginal rugae, tissue fragility/fissures/petechiae, urethral eversion or prolapse, loss of hymenal remnants,  prominence of urethral meatus, introital retraction and recurrent UTI.

Effects of vaginal rings with ulipristal acetate 

Contraception 2014 pii: S0010-7824(14)00609-X. doi: 10.1016/j.contraception.2014.08.006

A three-month contraceptive vaginal ring delivering ulipristal acetate (UPA-CVR) sounds easier to put in and take out than an intrauterine system. 

In this RCT, 55 women received a low-dose (1,500 microgram per day) or a high-dose (2,500 microgram per day) UPA-CVR for 24 weeks. 

They were monitored for ovulation by transvaginal ultrasound, hormone levels, bleeding patterns and endometrial thickness. 

Ovulation was only suppressed in 81.8% of the low-dose group and 86.1% in the high-dose group. This does not reach an acceptable efficacy, especially as there were occasional excessive withdrawal bleeds.

  • Dr Hope is a GP in Woodstock, Oxfordshire, and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Review patients taking colchicine. Should they be taking allopurinol and have they had uric acid and kidney checks in the past year?
  • At the next CCG commissioning meeting, discuss fast access to CT for patients with acute, severe depression.
  • In the next 10 patients aged >80 for whom you prescribe a PPI, measure vitamin B12 levels before starting and at six months, if they are still on medication, and check if there is a difference.

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