Journals Watch: Coronary stents and NSAIDs

Factors associated with early coronary stent thrombosis
JAMA 2011; 306: 1765-74
This study in France analysed clinical and genetic factors associated with early stent thrombosis. The study included 123 patients undergoing percutaneous coronary intervention (PCI) who had early stent thrombosis.

Out of the 15 different genes investigated, the study found that the significant determinants were CYP2C19 metabolic status (OR 1.99), ABCB1 3435 TT genotype (OR 2.16) and ITGB3 PLA2 carriage (OR 0.52).

Rather more relevant was a clinical model of non-genetic independent correlates which were: acuteness of PCI (OR 3.05); complex lesions (OR 2.33); left ventricular function less than 40 per cent (OR 2.25); diabetes mellitus (OR 1.82); higher clopidogrel loading doses (OR 0.73) and, most importantly, use of a PPI (OR 2.19).

This paper adds to the evidence that PPIs should not be used with patients who have just had a stent.

Folic acid supplements and language delay in children
JAMA 2011; 306: 1566-73
As GPs we advise women to take folic acid 400 microgram daily preconception and for the first 12 weeks of pregnancy to reduce the risk of spina bifida. Higher doses are required if the woman has had a previous spina bifida baby and/or if the woman is on antiepileptic medication, or other folate competing medication.

In the Norwegian mother and child cohort study, researchers looked at women who took folic acid preconception to eight weeks' gestation, and those who did not, and analysed the language delay in the children with three years' follow-up.

In about 39,000 children, 204 had severe language delay.

The OR was much lower (OR 0.55) for severe language delay if the mother had taken folic acid alone or with other vitamins.

This shows a strong correlation of not taking folic acid and language delay. I suspect this is an indicator of the chaotic lifestyle of the mothers, rather than an effect of folic acid.

HPV vaccine against anal intraepithelial neoplasia
N Engl J Med 2011; 365: 1576-85
HPV vaccine use was under the spotlight recently with the cost-effectiveness meta-analysis of the bivalent versus the quadrivalent vaccine, and arguments about the DoH decision to go with the bivalent vaccine in girls only.

Anal cancer rates are increasing in women and men, especially men who have sex with men. Infection with HPV, primarily HPV type 16 or 18, can cause high-grade anal intraepithelial neoplasia (grade 2 or 3), and then progress to cancer.

In this study, 602 healthy men who have sex with men (aged 16 to 26) were given either placebo or active quadrivalent HPV vaccine against HPV 6, 11, 16 and 18.

Rates of intraepithelial neoplasia were assessed. Rates of grade 2-3 anal intraepithelial neoplasia related to HPV 6, 11, 16 and 18 were reduced by 54.2 per cent in the vaccinated men. The vaccine has a favourable safety profile.

Vitamin E and the risk of prostate cancer
JAMA 2011; 306: 1549-56
This paper suggests that vitamins are not always beneficial. People with cancer often change their diet and take multivitamins. In this US study, 34,887 healthy men were randomised to receive selenium, vitamin E, both selenium and vitamin E, or placebo, and were followed up for a decade.

Compared with the placebo group, there was an increased risk of prostate cancer per 1,000 person-years of 1.6 for vitamin E, 0.8 for selenium and 0.4 for the combination of vitamin E and selenium. The conclusion is that vitamin E supplementation significantly increases prostate cancer risk in healthy men.

Briakinumab and methotrexate in psoriasis
N Engl J Med 2011; 365: 1586-96
This paper assessed the efficacy and safety of briakinumab, the latest monoclonal antibody against the p40 molecule, compared with methotrexate in patients with psoriasis.

Apparently the p40 molecule is shared by interleukin-12 and interleukin-23, which is overexpressed in psoriatic skin lesions.

This year-long trial compared four-weekly doses of briakinumab and methotrexate (dose varied between 5-25mg weekly). The authors used the PASI to assess psoriasis. At week 52, 66.2 per cent of the briakinumab group and only 23.9 per cent of the methotrexate group had a 75 per cent improvement in PASI score.

Side-effects were worse in the briakinumab group than the methotrexate group (9.1 per cent versus 6.1 per cent), but did not reach significance because the numbers were too small. The serious side-effects were infections and interval cancers.

NSAIDs in patients with stable rheumatoid arthritis
J Rheumatol 2011; 38: 2150-2
We now know that NSAIDs can increase the rate of cardiovascular deaths if used in the long term.

This study evaluated the effect of NSAID withdrawal on BP, 44-joint disease activity score and functional assessments in patients with stable rheumatoid arthritis (RA). This paper shows that you can withdraw NSAIDs in patients with stable RA.

Admittedly the numbers in the study were small (n=30) and the study period was only 12 weeks, but no patients went back onto NSAIDs during this time and their BP dropped by a mean 7mmHg. There was no significant deterioration in disease activity or function.

The authors conclude that NSAID withdrawal in patients with stable RA is possible and confers significant health benefit on BP and reducing cardiovascular risk.

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

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