Jan 12, 2018

Daily double

The story

The fewer the drugs, the fewer the pop-up alerts about drug-drug interactions to ignore when you place orders. Can 2 drugs compete with 3 in HIV?

The treatment paradigm

Flourescent lights in the hospital aren't helping anyone look younger this winter, but your HIV patients are truly getting old. Treatment veterans have been on triple antiretroviral therapy (ART) since 1996, when researchers showed that the addition of a second drug class to two nucleoside reverse transcriptase inhibitors suppressed HIV and boosted CD4 counts. But it was never clear whether the number of drugs or the number of drug classes was responsible for ART's success. Since an older treatment population will need more meds as they age, focus has returned to whether all 3 drugs are essential.   

The study

The SWORD trials looked at conventional 3-drug ART vs. a 2-drug regimen of dolutegravir (integrase inhibitor) and rilpivirine (NNRTI) in 1,000 highly-adherent patients with stable viral control on conventional therapy. The two drugs are dosed daily and were chosen due to excellent potency and side effect profiles. After 48 weeks, viral suppression was equal in both treatment groups. The 2-drug group reported more adverse effects, but this is common in HIV trials where patients switch from an ART therapy they've tolerated to a new regimen.

The takeaway

The SWORD trials are the largest to date to prove that a carefully chosen two-drug regimen is effective, and dolutegravir-rilpivirine is now FDA-approved for HIV patients with 6 months of viral suppression on conventional therapy.

Say it on rounds

When your biggest rock is moved to another service

Sometimes the best solution is transfer. Patients with spastic limb paralysis following stroke or other brain trauma are unlikely to recover function even with lengthy rehab. One idea: transfer a portion of the functioning spinal nerve on the unaffected limb to the spastic limb in an attempt to regain lost function. In a trial of 36 patients with partial unilateral paralysis from brain lesions, a nerve transfer of C7 led to drastic improvements in spasticity and sensorimotor scores compared to rehab alone. Long-term adverse effects were minimal.

When you're a doctor, and you haven't seen a doctor in years

Don't rush to the cath lab, but be aware that a study of middle-aged people without cardiovascular risk factors (non-smokers without hypertension, diabetes, or hyperlipidemia) found subclinical atherosclerosis in 50% of those tested. Ultrasound was used to find plaques and coronary artery calcifications as part of a larger study designed to evaluate early heart disease. LDL cholesterol was independently associated (see trend here) with the presence and extent of atherosclerosis, even at levels currently considered normal. 

When you stay late to help the new intern

It’ll pay off in the long run, right? A new shingles vaccine, brand-named Shingrix, is more effective in the elderly than the old stalwart Zostavax and can be used in immunocompromised patients. It's also more expensive. A cost effectiveness evaluation of Shingrix found that the vaccine was more than 80% likely to save money in the long run if used instead of Zostavax despite an upfront cost difference of roughly $140. The CDC recommends that all adults over age 50 receive the vaccine. 
JAMA Int Med

Brush up

The gut microbiome

You need your gut microbiome to protect you from pathogens, digest your food, synthesize vitamins, and develop and often tone down your immune system. Your bacterial flora, increasingly considered a distinct organ, is implicated in systemic inflammatory diseases like inflammatory bowel disease (IBD), rheumatoid arthritis, lupus, and multiple sclerosis. Diet, viral infections, and prior antibiotic exposure are all thought to play a role in dysbiosis, an imbalance between protective and pathogenic flora.

What's the evidence

For the role of the microbiome in IBD? The FOCUS trial of 2017 found that replacing dysbiotic gut microbiota with fecal matter transplant (FMT) from healthy donors tripled the rate of clinical remission compared to placebo in 80 patients with ulcerative colitis. FMT was given through colonoscopy infusion followed by self-administered enemas 5 days a week for 8 weeks. Specific bacteria (i.e. Fusobacterium) predicted failure of remission when present in the microbiota.

What your fitness friends are talking about

Butt, back, legs...face? After a research report last week found that regular facial exercise shaved a few years off of participants' appearance, it didn't take long for facial yoga to find its place in major newspapers.

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