Journals Watch - Stroke, Ayurvedics and internet drugs

Too busy to catch up on the latest research? Let Dr Raj Thakkar update you on recent papers.

Aspirin plus dipyridamole versus clopidogrel for stroke  N Engl J Med 2008 doi:10.1056/NEJMoa0805002
This double-blind randomised study looked at aspirin 25mg plus dipyridamole MR 200mg twice daily versus clopidogrel 75mg in patients with recurrent stroke.

The researchers looked at time to first stroke recurrence and incidence of other vascular events. This massive study followed more than 20,000 patients for approximately two and a half years.

A total of 916 (9.0 per cent) patients using aspirin plus dipyridamole suffered recurrent stroke while 898 (8.8 per cent) of patients on clopidogrel had recurrent stroke. The difference between the two groups was not statistically significant. There was no statistical difference between the two groups with respect to secondary outcomes.

More intracranial haemorrhagic events occurred in the aspirin group to statistical significance. Analysis of combined risk of recurrent stroke and major haemorrhagic event showed there was no statistical difference between the two groups.

The authors conclude neither regimen is superior and that we should prescribe what is most appropriate for the individual.

Stroke: consider which drug is most appropriate for the individual

Intensive lipid lowering with atorvastatin Mayo Clin Proc 2008; 83: 870-79
The Heart Protection Study put forward a convincing argument for the use of simvastatin in the secondary prevention of heart disease. The trial had many arms, including patients with diabetes.

The Treating to New Targets study showed, not unsurprisingly, that high-dosage atorvastatin conferred a mortality benefit compared with standard dosages. It is well known that diabetes is a major risk factor for vascular disease.

This double-blind randomised US study looked at the effect of high-dosage atorvastatin (80mg) versus low-dosage atorvastatin (10mg) in patients with both CHD and diabetes, with and without CKD (eGFR >60ml/min). Patients were followed up for an average of 4.8 years.

CKD increased the risk of cardiovascular disease from 13.4 to 17.4 per cent.

In those with CKD, cardiovascular events were reduced by 35 per cent relative risk reduction (RRR) and 7 per cent absolute risk reduction (ARR) in favour of high-dosage atorvastatin. In those without CKD, the RRR and ARR were 10 per cent and 1.3 per cent, respectively, again in favour of higher dosage atorvastatin.

The results from these trials suggest, at least in high-risk patients (those with cardiovascular disease, diabetes and CKD), high-dosage atorvstatin should be used. Questions remain as to how PCTs in the UK will react to this study, and how high-dosage simvastatin, the preferred UK statin, would fare in this high-risk population.

Antibiotic therapy for tonsillopharyngitis Mayo Clin Proc 2008; 83: 880-9
This interesting US study looked at the treatment of strep throat, apt given the recent NICE guidelines on respiratory tract infections. The main object of the meta-analysis was to evaluate whether a short course of antibiotics was appropriate in tonsillopharyngitis. Courses of five to seven days were compared with 10-day courses of antibiotics.

After analysis of 11 randomised controlled trials, short courses of oral penicillin were found to be inferior to longer courses at eradicating group A streptococcus, although this was not seen with cephalosporins. Eradication by short courses was poorer in children and teenagers.

This trial demonstrates that if we elect to treat URTIs, we should endeavour to prescribe an adequate course.

Corn consumption and diverticular disease  JAMA 2008; 300: 907-14
In order to reduce the risk of diverticulitis, we often advise our patients to reduce their consumption of nuts, corn and popcorn, but is there any evidence behind our advice?

This prospective questionnaire-based cohort study followed American men from 1986 to 2004. Nearly 50,000 men aged 40-75 were in the cohort. Men who had reported that they had been diagnosed with diverticular disease were sent more detailed questionnaires.

During the 18 year follow-up, 801 cases of diverticulitis and 383 cases of diverticular bleeding were reported.

Interestingly, those who consumed the most nuts and popcorn had the least risk of diverticulitis, while there was no association with corn consumption and diverticulitis. Nut, corn or popcorn consumption was not associated with diverticular bleeding.

Metal content of Ayurvedic medicines sold online  JAMA 2008; 300: 915-23
Ayurvedic medicine originates from ancient India and involves herbal remedies, sometimes combined with metals, minerals and gems (rasa shastra).

This study looked at whether Indian- and US-manufactured Ayurvedic medicines bought over the internet contained the toxic metals lead, mercury and arsenic. A total of 230 Ayurvedic medicines were randomly purchased from 25 websites. The researchers also looked at country of manufacture and whether the sites claimed good manufacturing practices.

A total of 193 medicines were received and analysed. A fifth of medicines contained metals. As expected, more rasa shastra medicines contained metals than non-rasa shastra. Rasa-shastra products also had higher concentrations of the toxic metals mercury and lead. Toxic metal levels were found to exceed the acceptable daily intake of metal-containing medicines.

It is clear we must warn our patients who are Ayurvedic medicine users to be vigilant about metal poisoning.

Prescribing PDE-5 inhibitors via e-medicine  Mayo Clin Proc 2008; 83: 890-6
Online medicine has opened the doors to poor medical practice, fraud and deception. Much internet abuse is focused on phosphodiesterase-5 (PDE-5) inhibitors for erectile dysfunction. Patients taking these drugs require appropriate assessment, counselling and follow-up.

This study assessed how well patients using a state-regulated internet-based prescribing system were managed compared with conventional practice. Patients with a variety of co-morbidities were involved in the retrospective study, including diabetes and hypertension. Six safety points were measured.

Perhaps surprisingly to UK doctors, safety and counselling were comparable. The number of inappropriate prescriptions did not differ between the two modes of medical delivery.

Lessons can be learned from this state-registered internet system. Perhaps a GMC-endorsed system may help to stamp out internet crime.

The quick study

  • Stroke patients can be treated effectively with either aspirin plus dipyridamole or clopidogrel
  • High-dosage atorvastatin is beneficial in patients with cardiovascular disease, diabetes and CKD.
  • Short-course penicillin was inferior to longer courses for the treatment of tonsillopharyngitis.
  • Diverticular bleeding was not associated with nut, corn or popcorn consumption.
  • Ayurvedic medicines were found to contain lead, mercury or arsenic.
  • Internet-based prescribing, when regulated, can be as safe as conventional practice.

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