Sherry Boschert

SAN FRANCISCO — Antiretroviral medications may protect against heart attacks or increase cardiovascular risk, depending on the drug and the duration of use, recent studies suggest.

“This is an extremely complicated issue,” Dr. Priscilla Hsue said at a meeting on HIV management that was sponsored by the University of California, San Francisco.

In general, the risk of MI appears to decrease in patients with HIV after starting most antiretroviral therapies, probably resulting from control of HIV-related inflammation, said Dr. Hsue, a cardiologist at the university. Two drugs, however, may increase the risk of MI with short-term use—abacavir and didanosine. Six studies (some not yet published) now have shown increased risk of MI with short-term abacavir, while three studies found no association between short-term abacavir and MI risk.

Other data show increased cardiovascular risk with long-term use of protease inhibitors, she added.

In the six studies showing increased risk of MI with short-term abacavir, patients tended to be older (in their mid-40s) than the patients in the three negative studies (mid- to late 30s), she noted. Patients in the six positive studies were highly treatment experienced, and most had an undetectable viral load. In the three negative studies, patients had no previous antiretroviral use and so had higher viral loads.

Some investigators have hypothesized that the negative cardiovascular effects of abacavir appear only in patients who are virally suppressed. 'That's most of the patients we see,” Dr. Hsue noted.

Prior to viral suppression, any increased cardiovascular risk from abacavir may be outweighed by abacavir's beneficial effects in reducing HIV-relate inflammation. “That's speculative. We need a lot more studies to look at that,” she continued.

The heart benefits of short-term control of HIV first became apparent with the Strategies for Management of Antiretroviral Therapy (SMART) study, which compared strategies of viral suppression with drug conservation (repeatedly starting and stopping therapy) in 5,472 patients. Patients in the drug conservation group were 57% more likely to have an MI, coronary intervention, or cardiovascular death, compared with the viral suppression group (N. Engl. J. Med. 2006;355:2283-96).

A separate study found improvements in endothelial function in 82 antiretroviral-naive patients after starting treatment for HIV in all three randomized treatment regimens. The vascular function improvements appeared as early as 4 weeks after starting therapy and were sustained through the 64-week study (J. Am. Coll. Cardiol. 2008;52:569-76).

“That was another important bit of evidence that antiretroviral therapy in the short term improves cardiovascular risk,” though risk levels were not reduced to normal levels, Dr. Hsue said.

Protease inhibitors were associated with a 16% relative increase in MI risk per drug exposure per year in the 23,437-patient Data Collection on Adverse Events of Anti-HIV Drugs (DAD) study (N. Engl. J. Med. 2007;356:1723-35). The study adjusted for the effects of dyslipidemia.

“The increased risk with protease inhibitors is not just associated with lipid abnormalities,” she noted.

A separate analysis of DAD study data launched the controversy regarding MI risk with abacavir and didanosine. Data on 517 MIs in 33,347 patients who were followed for 5 years suggested a 90% higher relative risk of MI with recent use of abacavir and a 49% higher risk with recent use of didanosine, compared with patients who did not recently use those drugs (Lancet 2008;371:1417-26).

“The study was highly controversial, and a surprise to everyone. It has since been confirmed in other studies,” Dr. Hsue said.

An unpublished analysis of SMART study data showed increased risk of cardiovascular disease with continuous use of abacavir, but not with didanosine. And an unpublished study done using the French Hospital Database found a doubling of MI risk in patients with exposure to abacavir in the past 6 months and cumulative exposure of less than 1 year. Another unpublished analysis of DAD study data reported increased MI risk with the use of protease inhibitors, recent use of didanosine, and both recent and cumulative exposure to abacavir, but no increased MI risk with several other antiretrovirals.

Physicians should keep these findings in perspective. More traditional cardiovascular risk factors play a much larger role in MI risk than do antiretrovirals in people with HIV, Dr. Hsue added.

“We spend millions of dollars talking about which antiretroviral medications increase cardiovascular risk, but smoking cessation is much more important” for reducing the risk of MI in patients with HIV, she said.

Disclosures: Dr. Hsue reported having no conflicts of interest.

Six studies, some of which are still unpublished, have shown increased risk of MI with short-term abacavir.

Source DR. HSUE

SAN FRANCISCO — Antiretroviral medications may protect against heart attacks or increase cardiovascular risk, depending on the drug and the duration of use, recent studies suggest.

“This is an extremely complicated issue,” Dr. Priscilla Hsue said at a meeting on HIV management that was sponsored by the University of California, San Francisco.

In general, the risk of MI appears to decrease in patients with HIV after starting most antiretroviral therapies, probably resulting from control of HIV-related inflammation, said Dr. Hsue, a cardiologist at the university. Two drugs, however, may increase the risk of MI with short-term use—abacavir and didanosine. Six studies (some not yet published) now have shown increased risk of MI with short-term abacavir, while three studies found no association between short-term abacavir and MI risk.

Other data show increased cardiovascular risk with long-term use of protease inhibitors, she added.

In the six studies showing increased risk of MI with short-term abacavir, patients tended to be older (in their mid-40s) than the patients in the three negative studies (mid- to late 30s), she noted. Patients in the six positive studies were highly treatment experienced, and most had an undetectable viral load. In the three negative studies, patients had no previous antiretroviral use and so had higher viral loads.

Some investigators have hypothesized that the negative cardiovascular effects of abacavir appear only in patients who are virally suppressed. 'That's most of the patients we see,” Dr. Hsue noted.

Prior to viral suppression, any increased cardiovascular risk from abacavir may be outweighed by abacavir's beneficial effects in reducing HIV-relate inflammation. “That's speculative. We need a lot more studies to look at that,” she continued.

The heart benefits of short-term control of HIV first became apparent with the Strategies for Management of Antiretroviral Therapy (SMART) study, which compared strategies of viral suppression with drug conservation (repeatedly starting and stopping therapy) in 5,472 patients. Patients in the drug conservation group were 57% more likely to have an MI, coronary intervention, or cardiovascular death, compared with the viral suppression group (N. Engl. J. Med. 2006;355:2283-96).

A separate study found improvements in endothelial function in 82 antiretroviral-naive patients after starting treatment for HIV in all three randomized treatment regimens. The vascular function improvements appeared as early as 4 weeks after starting therapy and were sustained through the 64-week study (J. Am. Coll. Cardiol. 2008;52:569-76).

“That was another important bit of evidence that antiretroviral therapy in the short term improves cardiovascular risk,” though risk levels were not reduced to normal levels, Dr. Hsue said.

Protease inhibitors were associated with a 16% relative increase in MI risk per drug exposure per year in the 23,437-patient Data Collection on Adverse Events of Anti-HIV Drugs (DAD) study (N. Engl. J. Med. 2007;356:1723-35). The study adjusted for the effects of dyslipidemia.

“The increased risk with protease inhibitors is not just associated with lipid abnormalities,” she noted.

A separate analysis of DAD study data launched the controversy regarding MI risk with abacavir and didanosine. Data on 517 MIs in 33,347 patients who were followed for 5 years suggested a 90% higher relative risk of MI with recent use of abacavir and a 49% higher risk with recent use of didanosine, compared with patients who did not recently use those drugs (Lancet 2008;371:1417-26).

“The study was highly controversial, and a surprise to everyone. It has since been confirmed in other studies,” Dr. Hsue said.

An unpublished analysis of SMART study data showed increased risk of cardiovascular disease with continuous use of abacavir, but not with didanosine. And an unpublished study done using the French Hospital Database found a doubling of MI risk in patients with exposure to abacavir in the past 6 months and cumulative exposure of less than 1 year. Another unpublished analysis of DAD study data reported increased MI risk with the use of protease inhibitors, recent use of didanosine, and both recent and cumulative exposure to abacavir, but no increased MI risk with several other antiretrovirals.

Physicians should keep these findings in perspective. More traditional cardiovascular risk factors play a much larger role in MI risk than do antiretrovirals in people with HIV, Dr. Hsue added.

“We spend millions of dollars talking about which antiretroviral medications increase cardiovascular risk, but smoking cessation is much more important” for reducing the risk of MI in patients with HIV, she said.

Disclosures: Dr. Hsue reported having no conflicts of interest.

Six studies, some of which are still unpublished, have shown increased risk of MI with short-term abacavir.

Source DR. HSUE

SAN FRANCISCO — Antiretroviral medications may protect against heart attacks or increase cardiovascular risk, depending on the drug and the duration of use, recent studies suggest.

“This is an extremely complicated issue,” Dr. Priscilla Hsue said at a meeting on HIV management that was sponsored by the University of California, San Francisco.

In general, the risk of MI appears to decrease in patients with HIV after starting most antiretroviral therapies, probably resulting from control of HIV-related inflammation, said Dr. Hsue, a cardiologist at the university. Two drugs, however, may increase the risk of MI with short-term use—abacavir and didanosine. Six studies (some not yet published) now have shown increased risk of MI with short-term abacavir, while three studies found no association between short-term abacavir and MI risk.

Other data show increased cardiovascular risk with long-term use of protease inhibitors, she added.

In the six studies showing increased risk of MI with short-term abacavir, patients tended to be older (in their mid-40s) than the patients in the three negative studies (mid- to late 30s), she noted. Patients in the six positive studies were highly treatment experienced, and most had an undetectable viral load. In the three negative studies, patients had no previous antiretroviral use and so had higher viral loads.

Some investigators have hypothesized that the negative cardiovascular effects of abacavir appear only in patients who are virally suppressed. 'That's most of the patients we see,” Dr. Hsue noted.

Prior to viral suppression, any increased cardiovascular risk from abacavir may be outweighed by abacavir's beneficial effects in reducing HIV-relate inflammation. “That's speculative. We need a lot more studies to look at that,” she continued.

The heart benefits of short-term control of HIV first became apparent with the Strategies for Management of Antiretroviral Therapy (SMART) study, which compared strategies of viral suppression with drug conservation (repeatedly starting and stopping therapy) in 5,472 patients. Patients in the drug conservation group were 57% more likely to have an MI, coronary intervention, or cardiovascular death, compared with the viral suppression group (N. Engl. J. Med. 2006;355:2283-96).

A separate study found improvements in endothelial function in 82 antiretroviral-naive patients after starting treatment for HIV in all three randomized treatment regimens. The vascular function improvements appeared as early as 4 weeks after starting therapy and were sustained through the 64-week study (J. Am. Coll. Cardiol. 2008;52:569-76).

“That was another important bit of evidence that antiretroviral therapy in the short term improves cardiovascular risk,” though risk levels were not reduced to normal levels, Dr. Hsue said.

Protease inhibitors were associated with a 16% relative increase in MI risk per drug exposure per year in the 23,437-patient Data Collection on Adverse Events of Anti-HIV Drugs (DAD) study (N. Engl. J. Med. 2007;356:1723-35). The study adjusted for the effects of dyslipidemia.

“The increased risk with protease inhibitors is not just associated with lipid abnormalities,” she noted.

A separate analysis of DAD study data launched the controversy regarding MI risk with abacavir and didanosine. Data on 517 MIs in 33,347 patients who were followed for 5 years suggested a 90% higher relative risk of MI with recent use of abacavir and a 49% higher risk with recent use of didanosine, compared with patients who did not recently use those drugs (Lancet 2008;371:1417-26).

“The study was highly controversial, and a surprise to everyone. It has since been confirmed in other studies,” Dr. Hsue said.

An unpublished analysis of SMART study data showed increased risk of cardiovascular disease with continuous use of abacavir, but not with didanosine. And an unpublished study done using the French Hospital Database found a doubling of MI risk in patients with exposure to abacavir in the past 6 months and cumulative exposure of less than 1 year. Another unpublished analysis of DAD study data reported increased MI risk with the use of protease inhibitors, recent use of didanosine, and both recent and cumulative exposure to abacavir, but no increased MI risk with several other antiretrovirals.

Physicians should keep these findings in perspective. More traditional cardiovascular risk factors play a much larger role in MI risk than do antiretrovirals in people with HIV, Dr. Hsue added.

“We spend millions of dollars talking about which antiretroviral medications increase cardiovascular risk, but smoking cessation is much more important” for reducing the risk of MI in patients with HIV, she said.

Disclosures: Dr. Hsue reported having no conflicts of interest.

Six studies, some of which are still unpublished, have shown increased risk of MI with short-term abacavir.

Source DR. HSUE

Major Finding: A majority (57%) of adults taking insulin for diabetes said they intentionally skipped an insulin injection occasionally and 20% did so regularly.

Data Source: Online survey with 502 participants in a sample weighted to be representative of insulin-using U.S. adults with diabetes.

Disclosures: Patton Medical Devices, which makes an insulin injection device, funded the study. Some of the investigators own stock in and have been advisers to the company.

Most adults with type 1 or type 2 diabetes intentionally skip insulin injections, and 20% skip them regularly, according to an online survey of 502 diabetic adults.

The study is one of the first to identify factors that were associated with a greater likelihood of purposefully omitting insulin shots at least occasionally, as 57% of respondents reported doing. The 388 respondents with type 2 diabetes were more likely to report intentional omissions of insulin, compared with the 114 with type 1 diabetes, according to the report published online Jan. 26 (Diabetes Care 2010;33:240-5).

Respondents who were more likely to skip insulin injections were younger, were students, had lower household incomes, had higher education levels, or did not eat a healthy diet. Skipping insulin also was more likely among those who either had to take more daily injections, said the injections interfered with daily activities, or reported pain or embarrassment from the injections.

Physicians should work with patients to discover their issues around injecting insulin and give them the information or tools they need to overcome some of these barriers, suggested Mark Peyrot, Ph.D., of the department of sociology, Loyola University Maryland, Baltimore, and his associates.

Insulin pens, finer-gauge needles, injection ports, needle-free injectors, and other device-related strategies can reduce pain or embarrassment. “However, we have found that patients do not feel that their health care providers are giving them adequate assistance in managing these problems, even when they raise the issue with their providers,” the investigators wrote.

Risk factors for intentionally skipping insulin injections differed for patients with type 1 and type 2 diabetes, separate analyses found. In respondents with type 1 diabetes, lack of a healthy diet, the number of daily insulin injections, and interference with daily activities were significantly associated with skipping insulin. In those with type 2 diabetes, age, education, income, pain, and embarrassment played greater roles in the risk for skipping insulin.

The investigators noted that insulin is used by more than 25% of people in the United States who have diabetes. Non-adherence with insulin regimens has been associated with higher hemoglobin A_1C levels and higher rates of hospitalization for diabetes-related complications.

Race and ethnicity were not associated with a likelihood of skipping insulin, contrary to findings in other studies, perhaps because the study controlled for the effects of income and education, or perhaps because the study did not have enough nonwhite participants. Whites comprised 73% of survey respondents, who were recruited by e-mail from the Harris Interactive Chronic Illness Panel.

Also contrary to some previous studies of adherence to insulin regimens, the current study found no significant association between omission of insulin and a history of depression, which surprised the investigators. This may be because the survey did not assess current depression.

Disabled respondents were less likely to skip an insulin injection, perhaps because they get more assistance with care or make a greater effort to attend to their health, the investigators speculated. They were not surprised that poor adherence with a healthy diet was associated with skipping insulin, as this has been reported before.

The survey's results suggest that intentional omission of insulin is a substantial problem, Katie Weinger, Ed.D., and Elizabeth A. Beverly, Ph.D., wrote in an editorial accompanying the report (Diabetes Care 2010;33:450-2).

The findings support previous studies that reported low levels of adherence to insulin regimens—intentional or not—in 59%–77% of patients with diabetes.

U.S. physicians are more likely than are doctors in other countries to delay prescribing insulin, and U.S. patients are less convinced of insulin's effectiveness and more likely to blame themselves for needing it, compared with patients in other countries, Dr. Weinger and Dr. Beverly noted. Physicians need to examine their own reluctance to initiate insulin and work with patients around these factors and the ones identified in Dr. Peyrot's study to minimize omission of insulin when needed, they suggested.

The few previous studies of reasons that patients skip insulin injections have focused mainly on patients with type 1 diabetes, especially on an association between eating disorders and insulin omission. The current study shows that not all insulin omission is motivated by desire to lose weight in patients with type 1 diabetes. It's unclear whether patients with type 2 diabetes think that skipping insulin will reduce weight.

Weight concerns were not addressed in the study. Neither were some other important issues, said Dr. Weinger, a researcher in the department of psychiatry at Harvard University, Boston, and Dr. Beverly, a researcher at the Joslin Diabetes Center, Boston. These issues include self-care behaviors, and the impact of insulin delivery systems. Nonetheless, the study provides an important look at the avoidance of insulin therapy.

Major Finding: A majority (57%) of adults taking insulin for diabetes said they intentionally skipped an insulin injection occasionally and 20% did so regularly.

Data Source: Online survey with 502 participants in a sample weighted to be representative of insulin-using U.S. adults with diabetes.

Disclosures: Patton Medical Devices, which makes an insulin injection device, funded the study. Some of the investigators own stock in and have been advisers to the company.

Most adults with type 1 or type 2 diabetes intentionally skip insulin injections, and 20% skip them regularly, according to an online survey of 502 diabetic adults.

The study is one of the first to identify factors that were associated with a greater likelihood of purposefully omitting insulin shots at least occasionally, as 57% of respondents reported doing. The 388 respondents with type 2 diabetes were more likely to report intentional omissions of insulin, compared with the 114 with type 1 diabetes, according to the report published online Jan. 26 (Diabetes Care 2010;33:240-5).

Respondents who were more likely to skip insulin injections were younger, were students, had lower household incomes, had higher education levels, or did not eat a healthy diet. Skipping insulin also was more likely among those who either had to take more daily injections, said the injections interfered with daily activities, or reported pain or embarrassment from the injections.

Physicians should work with patients to discover their issues around injecting insulin and give them the information or tools they need to overcome some of these barriers, suggested Mark Peyrot, Ph.D., of the department of sociology, Loyola University Maryland, Baltimore, and his associates.

Insulin pens, finer-gauge needles, injection ports, needle-free injectors, and other device-related strategies can reduce pain or embarrassment. “However, we have found that patients do not feel that their health care providers are giving them adequate assistance in managing these problems, even when they raise the issue with their providers,” the investigators wrote.

Risk factors for intentionally skipping insulin injections differed for patients with type 1 and type 2 diabetes, separate analyses found. In respondents with type 1 diabetes, lack of a healthy diet, the number of daily insulin injections, and interference with daily activities were significantly associated with skipping insulin. In those with type 2 diabetes, age, education, income, pain, and embarrassment played greater roles in the risk for skipping insulin.

The investigators noted that insulin is used by more than 25% of people in the United States who have diabetes. Non-adherence with insulin regimens has been associated with higher hemoglobin A_1C levels and higher rates of hospitalization for diabetes-related complications.

Race and ethnicity were not associated with a likelihood of skipping insulin, contrary to findings in other studies, perhaps because the study controlled for the effects of income and education, or perhaps because the study did not have enough nonwhite participants. Whites comprised 73% of survey respondents, who were recruited by e-mail from the Harris Interactive Chronic Illness Panel.

Also contrary to some previous studies of adherence to insulin regimens, the current study found no significant association between omission of insulin and a history of depression, which surprised the investigators. This may be because the survey did not assess current depression.

Disabled respondents were less likely to skip an insulin injection, perhaps because they get more assistance with care or make a greater effort to attend to their health, the investigators speculated. They were not surprised that poor adherence with a healthy diet was associated with skipping insulin, as this has been reported before.

The survey's results suggest that intentional omission of insulin is a substantial problem, Katie Weinger, Ed.D., and Elizabeth A. Beverly, Ph.D., wrote in an editorial accompanying the report (Diabetes Care 2010;33:450-2).

The findings support previous studies that reported low levels of adherence to insulin regimens—intentional or not—in 59%–77% of patients with diabetes.

U.S. physicians are more likely than are doctors in other countries to delay prescribing insulin, and U.S. patients are less convinced of insulin's effectiveness and more likely to blame themselves for needing it, compared with patients in other countries, Dr. Weinger and Dr. Beverly noted. Physicians need to examine their own reluctance to initiate insulin and work with patients around these factors and the ones identified in Dr. Peyrot's study to minimize omission of insulin when needed, they suggested.

The few previous studies of reasons that patients skip insulin injections have focused mainly on patients with type 1 diabetes, especially on an association between eating disorders and insulin omission. The current study shows that not all insulin omission is motivated by desire to lose weight in patients with type 1 diabetes. It's unclear whether patients with type 2 diabetes think that skipping insulin will reduce weight.

Weight concerns were not addressed in the study. Neither were some other important issues, said Dr. Weinger, a researcher in the department of psychiatry at Harvard University, Boston, and Dr. Beverly, a researcher at the Joslin Diabetes Center, Boston. These issues include self-care behaviors, and the impact of insulin delivery systems. Nonetheless, the study provides an important look at the avoidance of insulin therapy.

Major Finding: A majority (57%) of adults taking insulin for diabetes said they intentionally skipped an insulin injection occasionally and 20% did so regularly.

Data Source: Online survey with 502 participants in a sample weighted to be representative of insulin-using U.S. adults with diabetes.

Disclosures: Patton Medical Devices, which makes an insulin injection device, funded the study. Some of the investigators own stock in and have been advisers to the company.

Most adults with type 1 or type 2 diabetes intentionally skip insulin injections, and 20% skip them regularly, according to an online survey of 502 diabetic adults.

The study is one of the first to identify factors that were associated with a greater likelihood of purposefully omitting insulin shots at least occasionally, as 57% of respondents reported doing. The 388 respondents with type 2 diabetes were more likely to report intentional omissions of insulin, compared with the 114 with type 1 diabetes, according to the report published online Jan. 26 (Diabetes Care 2010;33:240-5).

Respondents who were more likely to skip insulin injections were younger, were students, had lower household incomes, had higher education levels, or did not eat a healthy diet. Skipping insulin also was more likely among those who either had to take more daily injections, said the injections interfered with daily activities, or reported pain or embarrassment from the injections.

Physicians should work with patients to discover their issues around injecting insulin and give them the information or tools they need to overcome some of these barriers, suggested Mark Peyrot, Ph.D., of the department of sociology, Loyola University Maryland, Baltimore, and his associates.

Insulin pens, finer-gauge needles, injection ports, needle-free injectors, and other device-related strategies can reduce pain or embarrassment. “However, we have found that patients do not feel that their health care providers are giving them adequate assistance in managing these problems, even when they raise the issue with their providers,” the investigators wrote.

Risk factors for intentionally skipping insulin injections differed for patients with type 1 and type 2 diabetes, separate analyses found. In respondents with type 1 diabetes, lack of a healthy diet, the number of daily insulin injections, and interference with daily activities were significantly associated with skipping insulin. In those with type 2 diabetes, age, education, income, pain, and embarrassment played greater roles in the risk for skipping insulin.

The investigators noted that insulin is used by more than 25% of people in the United States who have diabetes. Non-adherence with insulin regimens has been associated with higher hemoglobin A_1C levels and higher rates of hospitalization for diabetes-related complications.

Race and ethnicity were not associated with a likelihood of skipping insulin, contrary to findings in other studies, perhaps because the study controlled for the effects of income and education, or perhaps because the study did not have enough nonwhite participants. Whites comprised 73% of survey respondents, who were recruited by e-mail from the Harris Interactive Chronic Illness Panel.

Also contrary to some previous studies of adherence to insulin regimens, the current study found no significant association between omission of insulin and a history of depression, which surprised the investigators. This may be because the survey did not assess current depression.

Disabled respondents were less likely to skip an insulin injection, perhaps because they get more assistance with care or make a greater effort to attend to their health, the investigators speculated. They were not surprised that poor adherence with a healthy diet was associated with skipping insulin, as this has been reported before.

The survey's results suggest that intentional omission of insulin is a substantial problem, Katie Weinger, Ed.D., and Elizabeth A. Beverly, Ph.D., wrote in an editorial accompanying the report (Diabetes Care 2010;33:450-2).

The findings support previous studies that reported low levels of adherence to insulin regimens—intentional or not—in 59%–77% of patients with diabetes.

U.S. physicians are more likely than are doctors in other countries to delay prescribing insulin, and U.S. patients are less convinced of insulin's effectiveness and more likely to blame themselves for needing it, compared with patients in other countries, Dr. Weinger and Dr. Beverly noted. Physicians need to examine their own reluctance to initiate insulin and work with patients around these factors and the ones identified in Dr. Peyrot's study to minimize omission of insulin when needed, they suggested.

The few previous studies of reasons that patients skip insulin injections have focused mainly on patients with type 1 diabetes, especially on an association between eating disorders and insulin omission. The current study shows that not all insulin omission is motivated by desire to lose weight in patients with type 1 diabetes. It's unclear whether patients with type 2 diabetes think that skipping insulin will reduce weight.

Weight concerns were not addressed in the study. Neither were some other important issues, said Dr. Weinger, a researcher in the department of psychiatry at Harvard University, Boston, and Dr. Beverly, a researcher at the Joslin Diabetes Center, Boston. These issues include self-care behaviors, and the impact of insulin delivery systems. Nonetheless, the study provides an important look at the avoidance of insulin therapy.

SAN FRANCISCO — Antiretroviral medications may protect against heart attacks or increase cardiovascular risk, depending on the drug and the duration of use, recent studies suggest.

“This is an extremely complicated issue,” Dr. Priscilla Hsue said at a meeting on HIV management sponsored by the University of California, San Francisco.

In general, the risk of MI appears to decrease in patients with HIV after starting most antiretroviral therapies, probably resulting from control of HIV-related inflammation, said Dr. Hsue, a cardiologist at the university. Two drugs, however, may increase the risk of MI with short-term use—abacavir and didanosine. Six studies (some not yet published) now have shown increased risk of MI with short-term abacavir, while three studies found no association between short-term abacavir and MI risk. Other data show increased cardiovascular risk with long-term use of protease inhibitors, she added.

In the six studies showing increased risk of MI with short-term abacavir, patients tended to be older (in their mid-40s) than the patients in the three negative studies (mid- to late 30s), she noted. Patients in the six positive studies were highly treatment experienced, and most had an undetectable viral load. In the three negative studies, patients had no previous antiretroviral use and so had higher viral loads.

Some investigators have hypothesized that the negative cardiovascular effects of abacavir appear only in patients who are virally suppressed. 'That's most of the patients we see,” Dr. Hsue noted. Prior to viral suppression, any increased cardiovascular risk from abacavir may be outweighed by abacavir's beneficial effects in reducing HIV-related inflammation. “That's speculative. We need a lot more studies to look at that,” she said.

The heart benefits of short-term control of HIV first became apparent with the Strategies for Management of Antiretroviral Therapy (SMART) study, which compared strategies of viral suppression with drug conservation (repeatedly starting and stopping therapy) in 5,472 patients. Patients in the drug conservation group were 57% more likely to have an MI, coronary intervention, or cardiovascular death, compared with the viral suppression group (N. Engl. J. Med. 2006;355:2283-96).

A separate study found improvements in endothelial function in 82 antiretroviral-naive patients after starting treatment for HIV in all three randomized treatment regimens. The vascular function improvements appeared as early as 4 weeks after starting therapy and were sustained through the 64-week study (J. Am. Coll. Cardiol. 2008;52:569-76).

“That was another important bit of evidence that antiretroviral therapy in the short term improves cardiovascular risk,” though risk levels were not reduced to normal levels, Dr. Hsue said.

Protease inhibitors were associated with a 16% relative increase in MI risk per drug exposure per year in the 23,437-patient Data Collection on Adverse Events of Anti-HIV Drugs (DAD) study (N. Engl. J. Med. 2007;356:1723-35). The study adjusted for the effects of dyslipidemia. “The increased risk with protease inhibitors is not just associated with lipid abnormalities,” she noted.

A separate analysis of DAD study data launched the controversy regarding MI risk with abacavir and didanosine. Data on 517 MIs in 33,347 patients who were followed for 5 years suggested a 90% higher relative risk of MI with recent use of abacavir and a 49% higher risk with recent use of didanosine, compared with patients who did not recently use those drugs (Lancet 2008;371:1417-26).

“The study was highly controversial, and a surprise to everyone. It has since been confirmed in other studies,” Dr. Hsue said.

An unpublished analysis of SMART study data showed increased risk of cardiovascular disease with continuous use of abacavir, but not with didanosine.

And an unpublished study done using the French Hospital Database found a doubling of MI risk in patients with exposure to abacavir in the past 6 months and cumulative exposure of less than 1 year.

Another unpublished analysis of DAD study data reported increased MI risk with the use of protease inhibitors, recent use of didanosine, and both recent and cumulative exposure to abacavir, but no increased MI risk with several other antiretrovirals.

Physicians should keep these findings in perspective, Dr. Hsue advised. More traditional cardiovascular risk factors play a much larger role in MI risk than do antiretrovirals in people with HIV, she added.

“We spend millions of dollars talking about which antiretroviral medications increase cardiovascular risk, but smoking cessation is much more important” for reducing the risk of MI in patients with HIV, Dr. Hsue said.

Disclosures: Dr. Hsue reported having no conflicts of interest.

'The increased risk with protease inhibitors is not just associated with lipid abnormalities.'

Source DR. HSUE

SAN FRANCISCO — Antiretroviral medications may protect against heart attacks or increase cardiovascular risk, depending on the drug and the duration of use, recent studies suggest.

“This is an extremely complicated issue,” Dr. Priscilla Hsue said at a meeting on HIV management sponsored by the University of California, San Francisco.

In general, the risk of MI appears to decrease in patients with HIV after starting most antiretroviral therapies, probably resulting from control of HIV-related inflammation, said Dr. Hsue, a cardiologist at the university. Two drugs, however, may increase the risk of MI with short-term use—abacavir and didanosine. Six studies (some not yet published) now have shown increased risk of MI with short-term abacavir, while three studies found no association between short-term abacavir and MI risk. Other data show increased cardiovascular risk with long-term use of protease inhibitors, she added.

In the six studies showing increased risk of MI with short-term abacavir, patients tended to be older (in their mid-40s) than the patients in the three negative studies (mid- to late 30s), she noted. Patients in the six positive studies were highly treatment experienced, and most had an undetectable viral load. In the three negative studies, patients had no previous antiretroviral use and so had higher viral loads.

Some investigators have hypothesized that the negative cardiovascular effects of abacavir appear only in patients who are virally suppressed. 'That's most of the patients we see,” Dr. Hsue noted. Prior to viral suppression, any increased cardiovascular risk from abacavir may be outweighed by abacavir's beneficial effects in reducing HIV-related inflammation. “That's speculative. We need a lot more studies to look at that,” she said.

The heart benefits of short-term control of HIV first became apparent with the Strategies for Management of Antiretroviral Therapy (SMART) study, which compared strategies of viral suppression with drug conservation (repeatedly starting and stopping therapy) in 5,472 patients. Patients in the drug conservation group were 57% more likely to have an MI, coronary intervention, or cardiovascular death, compared with the viral suppression group (N. Engl. J. Med. 2006;355:2283-96).

A separate study found improvements in endothelial function in 82 antiretroviral-naive patients after starting treatment for HIV in all three randomized treatment regimens. The vascular function improvements appeared as early as 4 weeks after starting therapy and were sustained through the 64-week study (J. Am. Coll. Cardiol. 2008;52:569-76).

“That was another important bit of evidence that antiretroviral therapy in the short term improves cardiovascular risk,” though risk levels were not reduced to normal levels, Dr. Hsue said.

Protease inhibitors were associated with a 16% relative increase in MI risk per drug exposure per year in the 23,437-patient Data Collection on Adverse Events of Anti-HIV Drugs (DAD) study (N. Engl. J. Med. 2007;356:1723-35). The study adjusted for the effects of dyslipidemia. “The increased risk with protease inhibitors is not just associated with lipid abnormalities,” she noted.

A separate analysis of DAD study data launched the controversy regarding MI risk with abacavir and didanosine. Data on 517 MIs in 33,347 patients who were followed for 5 years suggested a 90% higher relative risk of MI with recent use of abacavir and a 49% higher risk with recent use of didanosine, compared with patients who did not recently use those drugs (Lancet 2008;371:1417-26).

“The study was highly controversial, and a surprise to everyone. It has since been confirmed in other studies,” Dr. Hsue said.

An unpublished analysis of SMART study data showed increased risk of cardiovascular disease with continuous use of abacavir, but not with didanosine.

And an unpublished study done using the French Hospital Database found a doubling of MI risk in patients with exposure to abacavir in the past 6 months and cumulative exposure of less than 1 year.

Another unpublished analysis of DAD study data reported increased MI risk with the use of protease inhibitors, recent use of didanosine, and both recent and cumulative exposure to abacavir, but no increased MI risk with several other antiretrovirals.

Physicians should keep these findings in perspective, Dr. Hsue advised. More traditional cardiovascular risk factors play a much larger role in MI risk than do antiretrovirals in people with HIV, she added.

“We spend millions of dollars talking about which antiretroviral medications increase cardiovascular risk, but smoking cessation is much more important” for reducing the risk of MI in patients with HIV, Dr. Hsue said.

Disclosures: Dr. Hsue reported having no conflicts of interest.

'The increased risk with protease inhibitors is not just associated with lipid abnormalities.'

Source DR. HSUE

SAN FRANCISCO — Antiretroviral medications may protect against heart attacks or increase cardiovascular risk, depending on the drug and the duration of use, recent studies suggest.

“This is an extremely complicated issue,” Dr. Priscilla Hsue said at a meeting on HIV management sponsored by the University of California, San Francisco.

In general, the risk of MI appears to decrease in patients with HIV after starting most antiretroviral therapies, probably resulting from control of HIV-related inflammation, said Dr. Hsue, a cardiologist at the university. Two drugs, however, may increase the risk of MI with short-term use—abacavir and didanosine. Six studies (some not yet published) now have shown increased risk of MI with short-term abacavir, while three studies found no association between short-term abacavir and MI risk. Other data show increased cardiovascular risk with long-term use of protease inhibitors, she added.

In the six studies showing increased risk of MI with short-term abacavir, patients tended to be older (in their mid-40s) than the patients in the three negative studies (mid- to late 30s), she noted. Patients in the six positive studies were highly treatment experienced, and most had an undetectable viral load. In the three negative studies, patients had no previous antiretroviral use and so had higher viral loads.

Some investigators have hypothesized that the negative cardiovascular effects of abacavir appear only in patients who are virally suppressed. 'That's most of the patients we see,” Dr. Hsue noted. Prior to viral suppression, any increased cardiovascular risk from abacavir may be outweighed by abacavir's beneficial effects in reducing HIV-related inflammation. “That's speculative. We need a lot more studies to look at that,” she said.

The heart benefits of short-term control of HIV first became apparent with the Strategies for Management of Antiretroviral Therapy (SMART) study, which compared strategies of viral suppression with drug conservation (repeatedly starting and stopping therapy) in 5,472 patients. Patients in the drug conservation group were 57% more likely to have an MI, coronary intervention, or cardiovascular death, compared with the viral suppression group (N. Engl. J. Med. 2006;355:2283-96).

A separate study found improvements in endothelial function in 82 antiretroviral-naive patients after starting treatment for HIV in all three randomized treatment regimens. The vascular function improvements appeared as early as 4 weeks after starting therapy and were sustained through the 64-week study (J. Am. Coll. Cardiol. 2008;52:569-76).

“That was another important bit of evidence that antiretroviral therapy in the short term improves cardiovascular risk,” though risk levels were not reduced to normal levels, Dr. Hsue said.

Protease inhibitors were associated with a 16% relative increase in MI risk per drug exposure per year in the 23,437-patient Data Collection on Adverse Events of Anti-HIV Drugs (DAD) study (N. Engl. J. Med. 2007;356:1723-35). The study adjusted for the effects of dyslipidemia. “The increased risk with protease inhibitors is not just associated with lipid abnormalities,” she noted.

A separate analysis of DAD study data launched the controversy regarding MI risk with abacavir and didanosine. Data on 517 MIs in 33,347 patients who were followed for 5 years suggested a 90% higher relative risk of MI with recent use of abacavir and a 49% higher risk with recent use of didanosine, compared with patients who did not recently use those drugs (Lancet 2008;371:1417-26).

“The study was highly controversial, and a surprise to everyone. It has since been confirmed in other studies,” Dr. Hsue said.

An unpublished analysis of SMART study data showed increased risk of cardiovascular disease with continuous use of abacavir, but not with didanosine.

And an unpublished study done using the French Hospital Database found a doubling of MI risk in patients with exposure to abacavir in the past 6 months and cumulative exposure of less than 1 year.

Another unpublished analysis of DAD study data reported increased MI risk with the use of protease inhibitors, recent use of didanosine, and both recent and cumulative exposure to abacavir, but no increased MI risk with several other antiretrovirals.

Physicians should keep these findings in perspective, Dr. Hsue advised. More traditional cardiovascular risk factors play a much larger role in MI risk than do antiretrovirals in people with HIV, she added.

“We spend millions of dollars talking about which antiretroviral medications increase cardiovascular risk, but smoking cessation is much more important” for reducing the risk of MI in patients with HIV, Dr. Hsue said.

Disclosures: Dr. Hsue reported having no conflicts of interest.

'The increased risk with protease inhibitors is not just associated with lipid abnormalities.'

Source DR. HSUE

Repairing skin barrier dysfunction due to environmental exposures and endogenous factors is essential for the optimal management of hand dermatitis.

The dysfunction also may be iatrogenic, which adds to morbidity by making the underlying eczema much harder to treat, Dr. Joseph F. Fowler Jr. explained at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Age, stress, ultraviolet radiation, low humidity, skin disease, and genetic factors can all lead to epidermal injury and inflammation, which may result in development of damage to the stratum corneum and dermis, causing a vicious cycle of further injury, noted Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum to block transepidermal water loss and to let the epidermis heal itself, he noted.

Second-generation moisturizers add emollients and humectants to bind water and lipids for temporary barrier improvement. Today's “regular” moisturizers offer occlusive and humectant activity, he explained. They are useful in situations of mild xerosis or transient subcutaneous damage in which normal healing processes are able to cope with the damage. They are not so effective for patients with prolonged subcutaneous damage, inflammation, or poor inherent repair ability (such as those with atopy).

Another barrier repair strategy is to use hydroxy acids or niacinamide to stimulate desquamation and skin repair, he added.

The newest products, third-generation moisturizers, have occlusive and humectant properties but also add ingredients to provide the raw materials for stimulating barrier repair and for anti-inflammatory effects.

Colloidal oatmeal is a third-generation moisturizer. Colloidal oatmeal products contain lipids such as linoleic acid, have an anti-inflammatory effect, and generally are free of common allergens such as preservatives.

MimyX, a cream containing palmitamide monoethanolamine (PEA), helps restore the skin barrier by mimicking the composition of skin barrier lipids (PEA, triglycerides, phospholipids, squalene, and phytosterol), according to data from Stiefel Laboratories, which markets MimyX. The PEA/lipid cream also mimics the lamellar structure of the skin barrier through a patented process, Dr. Fowler noted.

He recommended starting treatment for hand dermatitis with a class I or II topical steroid, plus adjunctive therapy with MimyX cream applied at least three times daily, or adjunctive therapy with high-strength (30%-40%) urea foam or lotion for hyperkeratotic, “psoriasiform” hand eczema.

Other options for initial adjunct therapy include a 12% ammonium lactate lotion or cream, which supports the epidermis and glycosaminoglycans in the dermis. Emollient effects from Eletone or Atopiclair creams may help, and other moisturizers may be useful for barrier repair, Dr. Fowler added. Tetrix is a new topical specifically promoted as a “barrier-repair” product, with early data showing some ability to block allergy to nickel and fragrances.

Disclosures: Dr. Fowler has been a consultant, speaker, or investigator for several companies that make skin care products and treatments, including Stiefel Laboratories.

SDEF and this news organization are owned by Elsevier.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum.

Source DR. FOWLER

Repairing skin barrier dysfunction due to environmental exposures and endogenous factors is essential for the optimal management of hand dermatitis.

The dysfunction also may be iatrogenic, which adds to morbidity by making the underlying eczema much harder to treat, Dr. Joseph F. Fowler Jr. explained at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Age, stress, ultraviolet radiation, low humidity, skin disease, and genetic factors can all lead to epidermal injury and inflammation, which may result in development of damage to the stratum corneum and dermis, causing a vicious cycle of further injury, noted Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum to block transepidermal water loss and to let the epidermis heal itself, he noted.

Second-generation moisturizers add emollients and humectants to bind water and lipids for temporary barrier improvement. Today's “regular” moisturizers offer occlusive and humectant activity, he explained. They are useful in situations of mild xerosis or transient subcutaneous damage in which normal healing processes are able to cope with the damage. They are not so effective for patients with prolonged subcutaneous damage, inflammation, or poor inherent repair ability (such as those with atopy).

Another barrier repair strategy is to use hydroxy acids or niacinamide to stimulate desquamation and skin repair, he added.

The newest products, third-generation moisturizers, have occlusive and humectant properties but also add ingredients to provide the raw materials for stimulating barrier repair and for anti-inflammatory effects.

Colloidal oatmeal is a third-generation moisturizer. Colloidal oatmeal products contain lipids such as linoleic acid, have an anti-inflammatory effect, and generally are free of common allergens such as preservatives.

MimyX, a cream containing palmitamide monoethanolamine (PEA), helps restore the skin barrier by mimicking the composition of skin barrier lipids (PEA, triglycerides, phospholipids, squalene, and phytosterol), according to data from Stiefel Laboratories, which markets MimyX. The PEA/lipid cream also mimics the lamellar structure of the skin barrier through a patented process, Dr. Fowler noted.

He recommended starting treatment for hand dermatitis with a class I or II topical steroid, plus adjunctive therapy with MimyX cream applied at least three times daily, or adjunctive therapy with high-strength (30%-40%) urea foam or lotion for hyperkeratotic, “psoriasiform” hand eczema.

Other options for initial adjunct therapy include a 12% ammonium lactate lotion or cream, which supports the epidermis and glycosaminoglycans in the dermis. Emollient effects from Eletone or Atopiclair creams may help, and other moisturizers may be useful for barrier repair, Dr. Fowler added. Tetrix is a new topical specifically promoted as a “barrier-repair” product, with early data showing some ability to block allergy to nickel and fragrances.

Disclosures: Dr. Fowler has been a consultant, speaker, or investigator for several companies that make skin care products and treatments, including Stiefel Laboratories.

SDEF and this news organization are owned by Elsevier.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum.

Source DR. FOWLER

Repairing skin barrier dysfunction due to environmental exposures and endogenous factors is essential for the optimal management of hand dermatitis.

The dysfunction also may be iatrogenic, which adds to morbidity by making the underlying eczema much harder to treat, Dr. Joseph F. Fowler Jr. explained at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Age, stress, ultraviolet radiation, low humidity, skin disease, and genetic factors can all lead to epidermal injury and inflammation, which may result in development of damage to the stratum corneum and dermis, causing a vicious cycle of further injury, noted Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum to block transepidermal water loss and to let the epidermis heal itself, he noted.

Second-generation moisturizers add emollients and humectants to bind water and lipids for temporary barrier improvement. Today's “regular” moisturizers offer occlusive and humectant activity, he explained. They are useful in situations of mild xerosis or transient subcutaneous damage in which normal healing processes are able to cope with the damage. They are not so effective for patients with prolonged subcutaneous damage, inflammation, or poor inherent repair ability (such as those with atopy).

Another barrier repair strategy is to use hydroxy acids or niacinamide to stimulate desquamation and skin repair, he added.

The newest products, third-generation moisturizers, have occlusive and humectant properties but also add ingredients to provide the raw materials for stimulating barrier repair and for anti-inflammatory effects.

Colloidal oatmeal is a third-generation moisturizer. Colloidal oatmeal products contain lipids such as linoleic acid, have an anti-inflammatory effect, and generally are free of common allergens such as preservatives.

MimyX, a cream containing palmitamide monoethanolamine (PEA), helps restore the skin barrier by mimicking the composition of skin barrier lipids (PEA, triglycerides, phospholipids, squalene, and phytosterol), according to data from Stiefel Laboratories, which markets MimyX. The PEA/lipid cream also mimics the lamellar structure of the skin barrier through a patented process, Dr. Fowler noted.

He recommended starting treatment for hand dermatitis with a class I or II topical steroid, plus adjunctive therapy with MimyX cream applied at least three times daily, or adjunctive therapy with high-strength (30%-40%) urea foam or lotion for hyperkeratotic, “psoriasiform” hand eczema.

Other options for initial adjunct therapy include a 12% ammonium lactate lotion or cream, which supports the epidermis and glycosaminoglycans in the dermis. Emollient effects from Eletone or Atopiclair creams may help, and other moisturizers may be useful for barrier repair, Dr. Fowler added. Tetrix is a new topical specifically promoted as a “barrier-repair” product, with early data showing some ability to block allergy to nickel and fragrances.

Disclosures: Dr. Fowler has been a consultant, speaker, or investigator for several companies that make skin care products and treatments, including Stiefel Laboratories.

SDEF and this news organization are owned by Elsevier.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum.

Source DR. FOWLER

SAN FRANCISCO — The “medical” use of marijuana, which is common among patients diagnosed with illnesses such as HIV or cancer, might lead to depression or anxiety disorders. However, data suggesting that marijuana use is a risk factor for throat and neck cancers are weak, two experts say.

Evidence that marijuana use might play an etiological role in the development of psychotic disorders and schizophrenia has been mounting (Eur. Arch. Psychiatry Clin. Neurosci. 2009;259:413-31; Am. J. Psychiatr. 2009;166:1251-7). The relationship between marijuana (or “pot”) and anxiety or mood disorders, however, is less clear, Dr. Robert B. Daroff Jr., director of the HIV Psychiatry Program at the San Francisco VA Medical Center, said at a meeting on the medical management of HIV sponsored by the University of California, San Francisco.

Patients with HIV often contend that they are self-medicating their symptoms and that the most common “diagnosis” associated with medical marijuana use is “stress,” he said.

“I usually advise—and this doesn't always go smoothly—that depressed or anxious patients take a trial off of pot before I treat their depression or their anxiety,” he said. If patients are willing to try interrupting marijuana use, often they will find that the drug was a major contributing factor to their psychiatric symptoms.

“At least for patients who have treatment-resistant depression and anxiety, we ought to be pushing harder for them to give a trial off of pot to see if that's related” to their psychiatric problem, he said.

Deborah Greenspan, D.Sc., professor and chair of orofacial sciences and distinguished professor of dentistry at the university, said anecdotal reports that the practice of using marijuana contributes to the development of oral squamous cell carcinoma (SCC) prompted her to review studies related to this topic.

A large, population-based case-control study with 407 subjects found no association between marijuana use and SCC either in the cohort as a whole or in any subgroup based on age, cigarette smoking status, or alcohol consumption (Cancer Res. 2004;64:4,049-54). “The bottom line is that, right now, there are no data to support marijuana as a risk factor” for oral SCC, she said at the meeting.

An analysis of five case-control studies with 4,029 cases of head and neck cancer and 5,015 control patients found no significant association between cancer and marijuana use in patients who did not smoke cigarettes (Cancer Epidemiol. Biomarkers Prev. 2009;18:1,544-51).

“There may have been some dual activity going on” from cigarette use by marijuana smokers that contributed to suggestions that marijuana increased cancer risk in some earlier small studies, Dr. Greenspan said.

Disclosures: Dr. Daroff and Dr. Greenspan reported having no relevant disclosures.

Depressed or anxious patients should take a trial off of pot before their depression or anxiety is treated.

Source DR. DAROFF

SAN FRANCISCO — The “medical” use of marijuana, which is common among patients diagnosed with illnesses such as HIV or cancer, might lead to depression or anxiety disorders. However, data suggesting that marijuana use is a risk factor for throat and neck cancers are weak, two experts say.

Evidence that marijuana use might play an etiological role in the development of psychotic disorders and schizophrenia has been mounting (Eur. Arch. Psychiatry Clin. Neurosci. 2009;259:413-31; Am. J. Psychiatr. 2009;166:1251-7). The relationship between marijuana (or “pot”) and anxiety or mood disorders, however, is less clear, Dr. Robert B. Daroff Jr., director of the HIV Psychiatry Program at the San Francisco VA Medical Center, said at a meeting on the medical management of HIV sponsored by the University of California, San Francisco.

Patients with HIV often contend that they are self-medicating their symptoms and that the most common “diagnosis” associated with medical marijuana use is “stress,” he said.

“I usually advise—and this doesn't always go smoothly—that depressed or anxious patients take a trial off of pot before I treat their depression or their anxiety,” he said. If patients are willing to try interrupting marijuana use, often they will find that the drug was a major contributing factor to their psychiatric symptoms.

“At least for patients who have treatment-resistant depression and anxiety, we ought to be pushing harder for them to give a trial off of pot to see if that's related” to their psychiatric problem, he said.

Deborah Greenspan, D.Sc., professor and chair of orofacial sciences and distinguished professor of dentistry at the university, said anecdotal reports that the practice of using marijuana contributes to the development of oral squamous cell carcinoma (SCC) prompted her to review studies related to this topic.

A large, population-based case-control study with 407 subjects found no association between marijuana use and SCC either in the cohort as a whole or in any subgroup based on age, cigarette smoking status, or alcohol consumption (Cancer Res. 2004;64:4,049-54). “The bottom line is that, right now, there are no data to support marijuana as a risk factor” for oral SCC, she said at the meeting.

An analysis of five case-control studies with 4,029 cases of head and neck cancer and 5,015 control patients found no significant association between cancer and marijuana use in patients who did not smoke cigarettes (Cancer Epidemiol. Biomarkers Prev. 2009;18:1,544-51).

“There may have been some dual activity going on” from cigarette use by marijuana smokers that contributed to suggestions that marijuana increased cancer risk in some earlier small studies, Dr. Greenspan said.

Disclosures: Dr. Daroff and Dr. Greenspan reported having no relevant disclosures.

Depressed or anxious patients should take a trial off of pot before their depression or anxiety is treated.

Source DR. DAROFF

SAN FRANCISCO — The “medical” use of marijuana, which is common among patients diagnosed with illnesses such as HIV or cancer, might lead to depression or anxiety disorders. However, data suggesting that marijuana use is a risk factor for throat and neck cancers are weak, two experts say.

Evidence that marijuana use might play an etiological role in the development of psychotic disorders and schizophrenia has been mounting (Eur. Arch. Psychiatry Clin. Neurosci. 2009;259:413-31; Am. J. Psychiatr. 2009;166:1251-7). The relationship between marijuana (or “pot”) and anxiety or mood disorders, however, is less clear, Dr. Robert B. Daroff Jr., director of the HIV Psychiatry Program at the San Francisco VA Medical Center, said at a meeting on the medical management of HIV sponsored by the University of California, San Francisco.

Patients with HIV often contend that they are self-medicating their symptoms and that the most common “diagnosis” associated with medical marijuana use is “stress,” he said.

“I usually advise—and this doesn't always go smoothly—that depressed or anxious patients take a trial off of pot before I treat their depression or their anxiety,” he said. If patients are willing to try interrupting marijuana use, often they will find that the drug was a major contributing factor to their psychiatric symptoms.

“At least for patients who have treatment-resistant depression and anxiety, we ought to be pushing harder for them to give a trial off of pot to see if that's related” to their psychiatric problem, he said.

Deborah Greenspan, D.Sc., professor and chair of orofacial sciences and distinguished professor of dentistry at the university, said anecdotal reports that the practice of using marijuana contributes to the development of oral squamous cell carcinoma (SCC) prompted her to review studies related to this topic.

A large, population-based case-control study with 407 subjects found no association between marijuana use and SCC either in the cohort as a whole or in any subgroup based on age, cigarette smoking status, or alcohol consumption (Cancer Res. 2004;64:4,049-54). “The bottom line is that, right now, there are no data to support marijuana as a risk factor” for oral SCC, she said at the meeting.

An analysis of five case-control studies with 4,029 cases of head and neck cancer and 5,015 control patients found no significant association between cancer and marijuana use in patients who did not smoke cigarettes (Cancer Epidemiol. Biomarkers Prev. 2009;18:1,544-51).

“There may have been some dual activity going on” from cigarette use by marijuana smokers that contributed to suggestions that marijuana increased cancer risk in some earlier small studies, Dr. Greenspan said.

Disclosures: Dr. Daroff and Dr. Greenspan reported having no relevant disclosures.

Depressed or anxious patients should take a trial off of pot before their depression or anxiety is treated.

Source DR. DAROFF

SAN DIEGO — Isotretinoin use was associated with a 68% increased risk for subsequent development of inflammatory bowel disease, particularly ulcerative colitis, in a retrospective case-control study of 30,021 patients.

The odds ratio of 1.68 for inflammatory bowel disease (IBD) in isotretinoin users compared with nonusers had a 95% confidence interval (CI) of 0.98-2.86, Dr. Seth Crockett and his associates reported in a poster presentation at the annual meeting of the American College of Gastroenterology.

The findings add to ongoing controversy that IBD risk with isotretinoin may have been a factor in the decision by Roche to pull the best-known brand of isotretinoin, Accutane, off the market in June 2009.

The current study examined a large administrative claims database with records on 55 million patients from more than 70 U.S. health plans. The investigators compared 8,189 patients with at least 12 months of continuous health plan enrollment and diagnoses of ulcerative colitis, Crohn's disease, or indeterminate IBD with three non-IBD control patients per IBD patient, matched by age, gender, and geographic region. They looked at exposure to isotretinoin in the 21,832 control patients during the first 12 months of health plan enrollment.

Results pointed to a possible dose-response effect: The risk for IBD increased with the number of isotretinoin prescriptions. Having four or more isotretinoin prescriptions was associated with an odds ratio of 2.67 for development of IBD (CI, 1.32-5.41), reported Dr. Crockett of the University of North Carolina, Chapel Hill.

Subgroup analyses showed a strong association between isotretinoin use and ulcerative colitis (odds ratio, 4.36; CI, 1.98-9.66) but no association between isotretinoin exposure and Crohn's disease (odds ratio, 0.68).

“The flip side of all this is that there are patients who desperately need isotretinoin,” Dr. Stephen P. Stone commented in an interview. “Those of us who care for people with acne and are aware of the physical and psychosocial aspects of it find it an indispensable drug,” said Dr. Stone, chair of the American Academy of Dermatology's task force on retinoids and professor at Southern Illinois University, Carbondale. The drug also is helpful for less common problems such as cutaneous lupus that do not respond to other treatments, he added.

The possible association between isotretinoin and IBD has long been included in label warnings, but it drew increased interest after a 2006 study by gastroenterologists at the University of Chicago. That study looked at all 85 cases of IBD in isotretinoin users reported to the Food and Drug Administration in 1997-2002 and graded the strength of causality using the Naranjo adverse drug reaction probability scale. Mean scores suggested that the oral retinoid was a “probable” cause of IBD (Am. J. Gastroenterol. 2006;101:1569-73). Some dermatologic experts criticized the study's methodology, saying that a one-point adjustment for accuracy in the probability ratings would downgrade the mean score to “possible.”

A separate study by gastroenterologists at the University of Manitoba, Winnipeg, found no significant association between isotretinoin use and IBD. Using a large government database and drug registry, they found that 1.2% of patients with IBD and 1.1% of matched patients without IBD used isotretinoin before IBD diagnosis, an insignificant difference (Am. J. Gastroenterol. 2009;104:2774-8).

Disclosures: Dr. Crockett and his associates reported having no conflicts of interest related to their study. Dr. Stone reported no conflicts of interest.

SAN DIEGO — Isotretinoin use was associated with a 68% increased risk for subsequent development of inflammatory bowel disease, particularly ulcerative colitis, in a retrospective case-control study of 30,021 patients.

The odds ratio of 1.68 for inflammatory bowel disease (IBD) in isotretinoin users compared with nonusers had a 95% confidence interval (CI) of 0.98-2.86, Dr. Seth Crockett and his associates reported in a poster presentation at the annual meeting of the American College of Gastroenterology.

The findings add to ongoing controversy that IBD risk with isotretinoin may have been a factor in the decision by Roche to pull the best-known brand of isotretinoin, Accutane, off the market in June 2009.

The current study examined a large administrative claims database with records on 55 million patients from more than 70 U.S. health plans. The investigators compared 8,189 patients with at least 12 months of continuous health plan enrollment and diagnoses of ulcerative colitis, Crohn's disease, or indeterminate IBD with three non-IBD control patients per IBD patient, matched by age, gender, and geographic region. They looked at exposure to isotretinoin in the 21,832 control patients during the first 12 months of health plan enrollment.

Results pointed to a possible dose-response effect: The risk for IBD increased with the number of isotretinoin prescriptions. Having four or more isotretinoin prescriptions was associated with an odds ratio of 2.67 for development of IBD (CI, 1.32-5.41), reported Dr. Crockett of the University of North Carolina, Chapel Hill.

Subgroup analyses showed a strong association between isotretinoin use and ulcerative colitis (odds ratio, 4.36; CI, 1.98-9.66) but no association between isotretinoin exposure and Crohn's disease (odds ratio, 0.68).

“The flip side of all this is that there are patients who desperately need isotretinoin,” Dr. Stephen P. Stone commented in an interview. “Those of us who care for people with acne and are aware of the physical and psychosocial aspects of it find it an indispensable drug,” said Dr. Stone, chair of the American Academy of Dermatology's task force on retinoids and professor at Southern Illinois University, Carbondale. The drug also is helpful for less common problems such as cutaneous lupus that do not respond to other treatments, he added.

The possible association between isotretinoin and IBD has long been included in label warnings, but it drew increased interest after a 2006 study by gastroenterologists at the University of Chicago. That study looked at all 85 cases of IBD in isotretinoin users reported to the Food and Drug Administration in 1997-2002 and graded the strength of causality using the Naranjo adverse drug reaction probability scale. Mean scores suggested that the oral retinoid was a “probable” cause of IBD (Am. J. Gastroenterol. 2006;101:1569-73). Some dermatologic experts criticized the study's methodology, saying that a one-point adjustment for accuracy in the probability ratings would downgrade the mean score to “possible.”

A separate study by gastroenterologists at the University of Manitoba, Winnipeg, found no significant association between isotretinoin use and IBD. Using a large government database and drug registry, they found that 1.2% of patients with IBD and 1.1% of matched patients without IBD used isotretinoin before IBD diagnosis, an insignificant difference (Am. J. Gastroenterol. 2009;104:2774-8).

Disclosures: Dr. Crockett and his associates reported having no conflicts of interest related to their study. Dr. Stone reported no conflicts of interest.

SAN DIEGO — Isotretinoin use was associated with a 68% increased risk for subsequent development of inflammatory bowel disease, particularly ulcerative colitis, in a retrospective case-control study of 30,021 patients.

The odds ratio of 1.68 for inflammatory bowel disease (IBD) in isotretinoin users compared with nonusers had a 95% confidence interval (CI) of 0.98-2.86, Dr. Seth Crockett and his associates reported in a poster presentation at the annual meeting of the American College of Gastroenterology.

The findings add to ongoing controversy that IBD risk with isotretinoin may have been a factor in the decision by Roche to pull the best-known brand of isotretinoin, Accutane, off the market in June 2009.

The current study examined a large administrative claims database with records on 55 million patients from more than 70 U.S. health plans. The investigators compared 8,189 patients with at least 12 months of continuous health plan enrollment and diagnoses of ulcerative colitis, Crohn's disease, or indeterminate IBD with three non-IBD control patients per IBD patient, matched by age, gender, and geographic region. They looked at exposure to isotretinoin in the 21,832 control patients during the first 12 months of health plan enrollment.

Results pointed to a possible dose-response effect: The risk for IBD increased with the number of isotretinoin prescriptions. Having four or more isotretinoin prescriptions was associated with an odds ratio of 2.67 for development of IBD (CI, 1.32-5.41), reported Dr. Crockett of the University of North Carolina, Chapel Hill.

Subgroup analyses showed a strong association between isotretinoin use and ulcerative colitis (odds ratio, 4.36; CI, 1.98-9.66) but no association between isotretinoin exposure and Crohn's disease (odds ratio, 0.68).

“The flip side of all this is that there are patients who desperately need isotretinoin,” Dr. Stephen P. Stone commented in an interview. “Those of us who care for people with acne and are aware of the physical and psychosocial aspects of it find it an indispensable drug,” said Dr. Stone, chair of the American Academy of Dermatology's task force on retinoids and professor at Southern Illinois University, Carbondale. The drug also is helpful for less common problems such as cutaneous lupus that do not respond to other treatments, he added.

The possible association between isotretinoin and IBD has long been included in label warnings, but it drew increased interest after a 2006 study by gastroenterologists at the University of Chicago. That study looked at all 85 cases of IBD in isotretinoin users reported to the Food and Drug Administration in 1997-2002 and graded the strength of causality using the Naranjo adverse drug reaction probability scale. Mean scores suggested that the oral retinoid was a “probable” cause of IBD (Am. J. Gastroenterol. 2006;101:1569-73). Some dermatologic experts criticized the study's methodology, saying that a one-point adjustment for accuracy in the probability ratings would downgrade the mean score to “possible.”

A separate study by gastroenterologists at the University of Manitoba, Winnipeg, found no significant association between isotretinoin use and IBD. Using a large government database and drug registry, they found that 1.2% of patients with IBD and 1.1% of matched patients without IBD used isotretinoin before IBD diagnosis, an insignificant difference (Am. J. Gastroenterol. 2009;104:2774-8).

Disclosures: Dr. Crockett and his associates reported having no conflicts of interest related to their study. Dr. Stone reported no conflicts of interest.

SAN DIEGO — Malnutrition was as likely in adults with inflammatory bowel disease as it was in children, a study of data on 385 patients showed.

The investigators were surprised to find statistically similar rates of malnutrition in 264 adults with IBD, compared with 121 pediatric cases—9% vs. 10%, respectively, Valerie Marcil, Ph.D., reported in an award-winning poster presentation at the annual meeting of the American College of Gastroenterology.

Malnutrition is common in IBD, and it had been thought that the added energy costs of growth in children and adolescents would make them more likely to be malnourished than were their adult counterparts.

Anemia was more common in pediatric patients (59%) than in adults (22%), while vitamin B₁₂ deficiency was seen more often in adults (12%) than in pediatric cases (5%), reported Dr. Marcil of McGill University, Montreal, and her associates. There were no significant differences between age groups in the percentage of patients who had low serum levels of iron (17% in adults and 22% in children) or folate (2% and 3%, respectively).

The investigators also divided the study participants into subgroups with Crohn's disease, ulcerative colitis, or unclassified colitis. The data showed that active Crohn's disease made malnutrition more likely in both adults and pediatric cases, compared with inactive disease.

Crohn's disease was the most common form of IBD in both adults (74%) and children (92%) in this study.

The cross-sectional comparison used data from four tertiary care centers in the university's IBD database.

SAN DIEGO — Malnutrition was as likely in adults with inflammatory bowel disease as it was in children, a study of data on 385 patients showed.

The investigators were surprised to find statistically similar rates of malnutrition in 264 adults with IBD, compared with 121 pediatric cases—9% vs. 10%, respectively, Valerie Marcil, Ph.D., reported in an award-winning poster presentation at the annual meeting of the American College of Gastroenterology.

Malnutrition is common in IBD, and it had been thought that the added energy costs of growth in children and adolescents would make them more likely to be malnourished than were their adult counterparts.

Anemia was more common in pediatric patients (59%) than in adults (22%), while vitamin B₁₂ deficiency was seen more often in adults (12%) than in pediatric cases (5%), reported Dr. Marcil of McGill University, Montreal, and her associates. There were no significant differences between age groups in the percentage of patients who had low serum levels of iron (17% in adults and 22% in children) or folate (2% and 3%, respectively).

The investigators also divided the study participants into subgroups with Crohn's disease, ulcerative colitis, or unclassified colitis. The data showed that active Crohn's disease made malnutrition more likely in both adults and pediatric cases, compared with inactive disease.

Crohn's disease was the most common form of IBD in both adults (74%) and children (92%) in this study.

The cross-sectional comparison used data from four tertiary care centers in the university's IBD database.

SAN DIEGO — Malnutrition was as likely in adults with inflammatory bowel disease as it was in children, a study of data on 385 patients showed.

The investigators were surprised to find statistically similar rates of malnutrition in 264 adults with IBD, compared with 121 pediatric cases—9% vs. 10%, respectively, Valerie Marcil, Ph.D., reported in an award-winning poster presentation at the annual meeting of the American College of Gastroenterology.

Malnutrition is common in IBD, and it had been thought that the added energy costs of growth in children and adolescents would make them more likely to be malnourished than were their adult counterparts.

Anemia was more common in pediatric patients (59%) than in adults (22%), while vitamin B₁₂ deficiency was seen more often in adults (12%) than in pediatric cases (5%), reported Dr. Marcil of McGill University, Montreal, and her associates. There were no significant differences between age groups in the percentage of patients who had low serum levels of iron (17% in adults and 22% in children) or folate (2% and 3%, respectively).

The investigators also divided the study participants into subgroups with Crohn's disease, ulcerative colitis, or unclassified colitis. The data showed that active Crohn's disease made malnutrition more likely in both adults and pediatric cases, compared with inactive disease.

Crohn's disease was the most common form of IBD in both adults (74%) and children (92%) in this study.

The cross-sectional comparison used data from four tertiary care centers in the university's IBD database.

SAN DIEGO — Among 366 patients with Barrett's esophagus, 82% were alive 5 years after diagnosis, a rate that was essentially no different than the overall survival rate seen in a matched control group from the general population.

The retrospective study is one of the first on survival in a large cohort of patients with Barrett's esophagus in the United States, Dr. Ganapathy A. Prasad said at the annual meeting of the American College of Gastroenterology.

Among previous studies, some found decreased survival in patients with Barrett's esophagus, compared with matched controls, while others showed comparable overall survival rates. Those data came predominantly from Europe, said Dr. Prasad of the Mayo Clinic, Rochester, Minn.

Dr. Prasad and his associates identified 401 patients with Barrett's esophagus in the Rochester Epidemiology Project who were diagnosed between January 1976 and January 2007, and excluded 35 who had some evidence of cancer or who developed cancer within 6 months of diagnosis.

The 366 patients in the study were followed for a mean of 7.1 years. They had a mean age of 62 years at baseline, 70% were male, and more than 85% were Caucasian. The investigators compared the study cohort's survival rate with survival data from an age- and gender-matched cohort from the U.S. Census for the white population in Minnesota.

Dr. Prasad noted that survival rates at 10 and 15 years after diagnosis also did not appear to diverge significantly between groups; the overall survival rates were 68% at 10 years and 58% at 15 years.

Barrett's esophagus was defined as a combination of endoscopically evident columnar mucosa at least 1 cm in size and histologic diagnosis of specialized intestinal metaplasia on biopsy.

At diagnosis, the mean segment length of the Barrett's esophagus was 4.8 cm, and 59% of patients had long-segment Barrett's esophagus. No dysplasia was apparent in 84% of patients, low-grade dysplasia was seen in 14%, and 2% had high-grade dysplasia at baseline.

The only predictors of death were older age and higher scores on the Charlson Comorbidity Index at the time of Barrett's esophagus diagnosis, a multivariate analysis showed. Neither male gender nor the presence of dysplasia affected survival significantly.

Among comorbidities at baseline, 24% of the Barrett's esophagus group had peptic ulcer, 18% had chronic pulmonary disease, 12% had diabetes, 11% had cerebrovascular disease, and 7% each had a history of MI, heart failure, peripheral vascular disease, or moderate to severe renal disease. Thirteen percent of the patients had cancers other than esophageal adenocarcinoma.

Only 5% of the 104 patients who died during follow-up died of esophageal adenocarcinoma. Cardiovascular disease was the leading cause of death (with 28% dying of cardiac causes and 4% dying of cerebrovascular causes), followed by deaths from nonesophageal neoplasms in 21% (colorectal, lung, hematologic, renal, and other cancers).

Disclosures: Dr. Prasad reported that he had no relevant conflicts of interest.

SAN DIEGO — Among 366 patients with Barrett's esophagus, 82% were alive 5 years after diagnosis, a rate that was essentially no different than the overall survival rate seen in a matched control group from the general population.

The retrospective study is one of the first on survival in a large cohort of patients with Barrett's esophagus in the United States, Dr. Ganapathy A. Prasad said at the annual meeting of the American College of Gastroenterology.

Among previous studies, some found decreased survival in patients with Barrett's esophagus, compared with matched controls, while others showed comparable overall survival rates. Those data came predominantly from Europe, said Dr. Prasad of the Mayo Clinic, Rochester, Minn.

Dr. Prasad and his associates identified 401 patients with Barrett's esophagus in the Rochester Epidemiology Project who were diagnosed between January 1976 and January 2007, and excluded 35 who had some evidence of cancer or who developed cancer within 6 months of diagnosis.

The 366 patients in the study were followed for a mean of 7.1 years. They had a mean age of 62 years at baseline, 70% were male, and more than 85% were Caucasian. The investigators compared the study cohort's survival rate with survival data from an age- and gender-matched cohort from the U.S. Census for the white population in Minnesota.

Dr. Prasad noted that survival rates at 10 and 15 years after diagnosis also did not appear to diverge significantly between groups; the overall survival rates were 68% at 10 years and 58% at 15 years.

Barrett's esophagus was defined as a combination of endoscopically evident columnar mucosa at least 1 cm in size and histologic diagnosis of specialized intestinal metaplasia on biopsy.

At diagnosis, the mean segment length of the Barrett's esophagus was 4.8 cm, and 59% of patients had long-segment Barrett's esophagus. No dysplasia was apparent in 84% of patients, low-grade dysplasia was seen in 14%, and 2% had high-grade dysplasia at baseline.

The only predictors of death were older age and higher scores on the Charlson Comorbidity Index at the time of Barrett's esophagus diagnosis, a multivariate analysis showed. Neither male gender nor the presence of dysplasia affected survival significantly.

Among comorbidities at baseline, 24% of the Barrett's esophagus group had peptic ulcer, 18% had chronic pulmonary disease, 12% had diabetes, 11% had cerebrovascular disease, and 7% each had a history of MI, heart failure, peripheral vascular disease, or moderate to severe renal disease. Thirteen percent of the patients had cancers other than esophageal adenocarcinoma.

Only 5% of the 104 patients who died during follow-up died of esophageal adenocarcinoma. Cardiovascular disease was the leading cause of death (with 28% dying of cardiac causes and 4% dying of cerebrovascular causes), followed by deaths from nonesophageal neoplasms in 21% (colorectal, lung, hematologic, renal, and other cancers).

Disclosures: Dr. Prasad reported that he had no relevant conflicts of interest.

SAN DIEGO — Among 366 patients with Barrett's esophagus, 82% were alive 5 years after diagnosis, a rate that was essentially no different than the overall survival rate seen in a matched control group from the general population.

The retrospective study is one of the first on survival in a large cohort of patients with Barrett's esophagus in the United States, Dr. Ganapathy A. Prasad said at the annual meeting of the American College of Gastroenterology.

Among previous studies, some found decreased survival in patients with Barrett's esophagus, compared with matched controls, while others showed comparable overall survival rates. Those data came predominantly from Europe, said Dr. Prasad of the Mayo Clinic, Rochester, Minn.

Dr. Prasad and his associates identified 401 patients with Barrett's esophagus in the Rochester Epidemiology Project who were diagnosed between January 1976 and January 2007, and excluded 35 who had some evidence of cancer or who developed cancer within 6 months of diagnosis.

The 366 patients in the study were followed for a mean of 7.1 years. They had a mean age of 62 years at baseline, 70% were male, and more than 85% were Caucasian. The investigators compared the study cohort's survival rate with survival data from an age- and gender-matched cohort from the U.S. Census for the white population in Minnesota.

Dr. Prasad noted that survival rates at 10 and 15 years after diagnosis also did not appear to diverge significantly between groups; the overall survival rates were 68% at 10 years and 58% at 15 years.

Barrett's esophagus was defined as a combination of endoscopically evident columnar mucosa at least 1 cm in size and histologic diagnosis of specialized intestinal metaplasia on biopsy.

At diagnosis, the mean segment length of the Barrett's esophagus was 4.8 cm, and 59% of patients had long-segment Barrett's esophagus. No dysplasia was apparent in 84% of patients, low-grade dysplasia was seen in 14%, and 2% had high-grade dysplasia at baseline.

The only predictors of death were older age and higher scores on the Charlson Comorbidity Index at the time of Barrett's esophagus diagnosis, a multivariate analysis showed. Neither male gender nor the presence of dysplasia affected survival significantly.

Among comorbidities at baseline, 24% of the Barrett's esophagus group had peptic ulcer, 18% had chronic pulmonary disease, 12% had diabetes, 11% had cerebrovascular disease, and 7% each had a history of MI, heart failure, peripheral vascular disease, or moderate to severe renal disease. Thirteen percent of the patients had cancers other than esophageal adenocarcinoma.

Only 5% of the 104 patients who died during follow-up died of esophageal adenocarcinoma. Cardiovascular disease was the leading cause of death (with 28% dying of cardiac causes and 4% dying of cerebrovascular causes), followed by deaths from nonesophageal neoplasms in 21% (colorectal, lung, hematologic, renal, and other cancers).

Disclosures: Dr. Prasad reported that he had no relevant conflicts of interest.

Women who used hormone therapy were more likely to need cataract surgery, a risk potentiated by drinking alcohol, a large Swedish prospective study found.

In a 98-month study of 30,861 postmenopausal women, those who had ever used hormone therapy (HT) had a 14% higher risk for cataract extraction and current HT users had an 18% higher risk, compared with women who never used HT in a multivariate analysis, Dr. Birgitta Ejdervik Lindblad and her associates reported (Ophthalmology 2010 Jan. 4 [doi:10.1016/j.ophtha.2009.07.046

Cataract extraction was even more likely in women who were using HT and drank alcohol. Among current HT users, any alcohol consumption was associated with a 29% higher risk for cataract extraction, and those who drank more than one alcoholic drink per day had a 42% higher risk, compared with women who were neither using HT nor drinking alcohol. (One drink was defined as about 13 g of alcohol, roughly equal to one glass of wine, bottle of beer, or drink of liquor.) Drinking alcohol has been associated with increased levels of plasma estrogen in postmenopausal women in prior studies.

Investigators collected data from women in the Swedish Mammography Cohort who completed questionnaires in September 1997 about hormone status, use of hormone therapy, and lifestyle factors. The researchers followed them through October 2005 and compared their names with those on Swedish registers of cataract surgeries, which identified 4,324 women who underwent cataract surgery during the study period.

Among women aged 65 years or older, the risk for cataract surgery was 73% higher in those using hormone therapy, compared with women who never used HT, after the researchers adjusted for the effects of alcohol consumption, smoking, diabetes, hypertension, steroid or vitamin use, body mass index, and education level.

Longer use of HT was associated with higher risk for cataract extraction in a linear fashion, added Dr. Lindblad of the Karolinska Institute, Stockholm. Current users of hormone therapy reported longer duration of HT (a mean of 6 years) compared with past users (4 years). Women who used HT for more than 10 years had a 20% higher risk of cataract extraction, compared with women who never used HT.

If the current study's findings can be confirmed, the increased risk for cataract extraction should be added to the list of increased risks for breast cancer and cardiovascular disease that are associated with HT use, the investigators suggested.

Previous studies provided scarce and inconsistent evidence of any potential association between HT use and the risk of age-related cataracts.

Dr. Lindblad and her associates advised caution in comparing their study with those conducted outside of Sweden because HT preparations and clinical practices vary between countries. The different chemistries might have different effects on the body.

At the start of the study, 39% of women were using hormone therapy, 11% had used HT in the past, and 50% had never used HT. Half of current users took HT to relieve hot flushes, 33% used it for urogenital symptoms, and 17% took HT for both types of symptoms.

The risk for cataract extraction in women using HT did not differ significantly based on current or past cigarette smoking.

Disclosures: The researchers reported having no conflicts of interest related to the study, funded by Swedish government agencies and research foundations.

Women who used hormone therapy were more likely to need cataract surgery, a risk potentiated by drinking alcohol, a large Swedish prospective study found.

In a 98-month study of 30,861 postmenopausal women, those who had ever used hormone therapy (HT) had a 14% higher risk for cataract extraction and current HT users had an 18% higher risk, compared with women who never used HT in a multivariate analysis, Dr. Birgitta Ejdervik Lindblad and her associates reported (Ophthalmology 2010 Jan. 4 [doi:10.1016/j.ophtha.2009.07.046

Cataract extraction was even more likely in women who were using HT and drank alcohol. Among current HT users, any alcohol consumption was associated with a 29% higher risk for cataract extraction, and those who drank more than one alcoholic drink per day had a 42% higher risk, compared with women who were neither using HT nor drinking alcohol. (One drink was defined as about 13 g of alcohol, roughly equal to one glass of wine, bottle of beer, or drink of liquor.) Drinking alcohol has been associated with increased levels of plasma estrogen in postmenopausal women in prior studies.

Investigators collected data from women in the Swedish Mammography Cohort who completed questionnaires in September 1997 about hormone status, use of hormone therapy, and lifestyle factors. The researchers followed them through October 2005 and compared their names with those on Swedish registers of cataract surgeries, which identified 4,324 women who underwent cataract surgery during the study period.

Among women aged 65 years or older, the risk for cataract surgery was 73% higher in those using hormone therapy, compared with women who never used HT, after the researchers adjusted for the effects of alcohol consumption, smoking, diabetes, hypertension, steroid or vitamin use, body mass index, and education level.

Longer use of HT was associated with higher risk for cataract extraction in a linear fashion, added Dr. Lindblad of the Karolinska Institute, Stockholm. Current users of hormone therapy reported longer duration of HT (a mean of 6 years) compared with past users (4 years). Women who used HT for more than 10 years had a 20% higher risk of cataract extraction, compared with women who never used HT.

If the current study's findings can be confirmed, the increased risk for cataract extraction should be added to the list of increased risks for breast cancer and cardiovascular disease that are associated with HT use, the investigators suggested.

Previous studies provided scarce and inconsistent evidence of any potential association between HT use and the risk of age-related cataracts.

Dr. Lindblad and her associates advised caution in comparing their study with those conducted outside of Sweden because HT preparations and clinical practices vary between countries. The different chemistries might have different effects on the body.

At the start of the study, 39% of women were using hormone therapy, 11% had used HT in the past, and 50% had never used HT. Half of current users took HT to relieve hot flushes, 33% used it for urogenital symptoms, and 17% took HT for both types of symptoms.

The risk for cataract extraction in women using HT did not differ significantly based on current or past cigarette smoking.

Disclosures: The researchers reported having no conflicts of interest related to the study, funded by Swedish government agencies and research foundations.

Women who used hormone therapy were more likely to need cataract surgery, a risk potentiated by drinking alcohol, a large Swedish prospective study found.

In a 98-month study of 30,861 postmenopausal women, those who had ever used hormone therapy (HT) had a 14% higher risk for cataract extraction and current HT users had an 18% higher risk, compared with women who never used HT in a multivariate analysis, Dr. Birgitta Ejdervik Lindblad and her associates reported (Ophthalmology 2010 Jan. 4 [doi:10.1016/j.ophtha.2009.07.046

Cataract extraction was even more likely in women who were using HT and drank alcohol. Among current HT users, any alcohol consumption was associated with a 29% higher risk for cataract extraction, and those who drank more than one alcoholic drink per day had a 42% higher risk, compared with women who were neither using HT nor drinking alcohol. (One drink was defined as about 13 g of alcohol, roughly equal to one glass of wine, bottle of beer, or drink of liquor.) Drinking alcohol has been associated with increased levels of plasma estrogen in postmenopausal women in prior studies.

Investigators collected data from women in the Swedish Mammography Cohort who completed questionnaires in September 1997 about hormone status, use of hormone therapy, and lifestyle factors. The researchers followed them through October 2005 and compared their names with those on Swedish registers of cataract surgeries, which identified 4,324 women who underwent cataract surgery during the study period.

Among women aged 65 years or older, the risk for cataract surgery was 73% higher in those using hormone therapy, compared with women who never used HT, after the researchers adjusted for the effects of alcohol consumption, smoking, diabetes, hypertension, steroid or vitamin use, body mass index, and education level.

Longer use of HT was associated with higher risk for cataract extraction in a linear fashion, added Dr. Lindblad of the Karolinska Institute, Stockholm. Current users of hormone therapy reported longer duration of HT (a mean of 6 years) compared with past users (4 years). Women who used HT for more than 10 years had a 20% higher risk of cataract extraction, compared with women who never used HT.

If the current study's findings can be confirmed, the increased risk for cataract extraction should be added to the list of increased risks for breast cancer and cardiovascular disease that are associated with HT use, the investigators suggested.

Previous studies provided scarce and inconsistent evidence of any potential association between HT use and the risk of age-related cataracts.

Dr. Lindblad and her associates advised caution in comparing their study with those conducted outside of Sweden because HT preparations and clinical practices vary between countries. The different chemistries might have different effects on the body.

At the start of the study, 39% of women were using hormone therapy, 11% had used HT in the past, and 50% had never used HT. Half of current users took HT to relieve hot flushes, 33% used it for urogenital symptoms, and 17% took HT for both types of symptoms.

The risk for cataract extraction in women using HT did not differ significantly based on current or past cigarette smoking.

Disclosures: The researchers reported having no conflicts of interest related to the study, funded by Swedish government agencies and research foundations.

Major Finding: When opioids were used long-term for noncancer pain, 6%-23% of patients stopped taking them due to inefficacy or side effects and 0.3% developed signs of addiction.

Data Source: Cochrane Collaboration review of 26 clinical studies with 4,893 participants.

Disclosures: None were reported in relation to the review.

One of the first systematic reviews of data on long-term use of opioids found weak evidence to support the idea that adults who can take chronic opioids get chronic pain relief, though effects on function or quality of life are unclear.

In a Cochrane Collaboration review of 26 prospective studies with 4,893 participants, 6%-23% of patients (depending on the route of drug administration) dropped out of the clinical trials due to inefficacy or side effects, but those who finished the studies maintained clinically significant reductions in pain for up to 48 months, Meredith Noble and her associates reported.

The review also suggested that opioid abuse or addiction were rare, but acknowledged that the findings are compromised by the limited quantity and poor quality of the studies. Only 7 (0.3%) of 2,613 patients developed signs of addiction or took their medicine inappropriately in the studies that reported those outcomes (Cochrane Database Syst. Rev. 2010 [doi: 10.1002/14651858.CD006605

Most of the studies excluded patients with risk factors for abuse. The low rate of addiction may be generalizable only to patients with no history of abuse or addiction, wrote Ms. Noble, a senior research analyst at the Economic Cycle Research Institute, one of 14 evidence-based practice centers under the Agency for Healthcare Research and Quality. A previous study suggested that addiction or abuse may develop in 3% of patients in all studies of opioid use for chronic pain and in 0.2% of patients in studies that screened out participants with a history of abuse or addiction (Pain Med. 2008;9:444-59).

The evidence of long-term relief of noncancer pain with chronic opioid use was too sparse in the current review to draw firm conclusions, the investigators said.

Among 3,040 patients taking oral opioids, 23% discontinued treatment due to adverse effects and 10% dropped out because of insufficient pain relief. Among 1,628 on transdermal opioids, 12% stopped due to adverse effects and 6% stopped due to insufficient pain relief. Intrathecal pumps delivered opioids in 231 patients who could not find pain relief any other way; of these, 9% stopped due to adverse effects and 8% dropped out due to insufficient pain relief.

One of the studies in the review was a randomized trial comparing two opioids; the other 25 studies were case series or uncontrolled continuations of short-term trials of opioids for noncancer pain. None included comparisons with placebo or nonopioid therapies.

The only other systematic review of opioid use for chronic noncancer pain was a 2008 study by the same investigators.

Solid estimates are lacking for the number of people with chronic noncancer pain who are taking opioids long-term. Two U.S. studies suggest that 0.65% of people with medical insurance use opioids chronically.

However, two pain experts said in interviews they fear clinicians might read too much into the review's limited findings.

The report is “very encouraging, but it's far from the whole story,” Dr. Perry Fine said. Because there are no good substitutes for opioids on the horizon, physicians need to find ways to make long-term opioid use more effective and safe, he said.

Dr. Fine, president of the American Academy of Pain Medicine (AAPM) and professor of anesthesiology at the University of Utah, Salt Lake City, compared current use of long-term opioids for noncancer pain with the use of surgical anesthesia 20-30 years ago when it had significant morbidity and mortality. “That didn't stop us from doing surgical procedures when necessary, but it did motivate research and improvements.”

Primary care internist Dr. Roger Chou said that the 0.3% rate of addiction reported is “a little misleading, because it's based on pretty crummy data.” The review's findings on addiction, pain relief, and adverse events apply to very select groups of patients, not the more complicated cases that raise concerns for physicians considering long-term opioids.

Mainly, the review shows how little is known about prescribing long-term opioids, suggested Dr. Chou, of Oregon Health and Science University, Portland, and lead author of clinical guidelines on chronic opioids for noncancer pain by the American Pain Society and the AAPM. “We really don't have good quality, long-term data on this, which is scary because we're prescribing these medications so much,” Dr. Chou said.

Disclosures: Neither commentator is associated with the Cochrane review. Dr. Chou reported no conflicts of interest. Dr. Fine has been a speaker for Wyeth and an adviser for many pharmaceutical companies that manufacture opioids.

Major Finding: When opioids were used long-term for noncancer pain, 6%-23% of patients stopped taking them due to inefficacy or side effects and 0.3% developed signs of addiction.

Data Source: Cochrane Collaboration review of 26 clinical studies with 4,893 participants.

Disclosures: None were reported in relation to the review.

One of the first systematic reviews of data on long-term use of opioids found weak evidence to support the idea that adults who can take chronic opioids get chronic pain relief, though effects on function or quality of life are unclear.

In a Cochrane Collaboration review of 26 prospective studies with 4,893 participants, 6%-23% of patients (depending on the route of drug administration) dropped out of the clinical trials due to inefficacy or side effects, but those who finished the studies maintained clinically significant reductions in pain for up to 48 months, Meredith Noble and her associates reported.

The review also suggested that opioid abuse or addiction were rare, but acknowledged that the findings are compromised by the limited quantity and poor quality of the studies. Only 7 (0.3%) of 2,613 patients developed signs of addiction or took their medicine inappropriately in the studies that reported those outcomes (Cochrane Database Syst. Rev. 2010 [doi: 10.1002/14651858.CD006605

Most of the studies excluded patients with risk factors for abuse. The low rate of addiction may be generalizable only to patients with no history of abuse or addiction, wrote Ms. Noble, a senior research analyst at the Economic Cycle Research Institute, one of 14 evidence-based practice centers under the Agency for Healthcare Research and Quality. A previous study suggested that addiction or abuse may develop in 3% of patients in all studies of opioid use for chronic pain and in 0.2% of patients in studies that screened out participants with a history of abuse or addiction (Pain Med. 2008;9:444-59).

The evidence of long-term relief of noncancer pain with chronic opioid use was too sparse in the current review to draw firm conclusions, the investigators said.

Among 3,040 patients taking oral opioids, 23% discontinued treatment due to adverse effects and 10% dropped out because of insufficient pain relief. Among 1,628 on transdermal opioids, 12% stopped due to adverse effects and 6% stopped due to insufficient pain relief. Intrathecal pumps delivered opioids in 231 patients who could not find pain relief any other way; of these, 9% stopped due to adverse effects and 8% dropped out due to insufficient pain relief.

One of the studies in the review was a randomized trial comparing two opioids; the other 25 studies were case series or uncontrolled continuations of short-term trials of opioids for noncancer pain. None included comparisons with placebo or nonopioid therapies.

The only other systematic review of opioid use for chronic noncancer pain was a 2008 study by the same investigators.

Solid estimates are lacking for the number of people with chronic noncancer pain who are taking opioids long-term. Two U.S. studies suggest that 0.65% of people with medical insurance use opioids chronically.

However, two pain experts said in interviews they fear clinicians might read too much into the review's limited findings.

The report is “very encouraging, but it's far from the whole story,” Dr. Perry Fine said. Because there are no good substitutes for opioids on the horizon, physicians need to find ways to make long-term opioid use more effective and safe, he said.

Dr. Fine, president of the American Academy of Pain Medicine (AAPM) and professor of anesthesiology at the University of Utah, Salt Lake City, compared current use of long-term opioids for noncancer pain with the use of surgical anesthesia 20-30 years ago when it had significant morbidity and mortality. “That didn't stop us from doing surgical procedures when necessary, but it did motivate research and improvements.”

Primary care internist Dr. Roger Chou said that the 0.3% rate of addiction reported is “a little misleading, because it's based on pretty crummy data.” The review's findings on addiction, pain relief, and adverse events apply to very select groups of patients, not the more complicated cases that raise concerns for physicians considering long-term opioids.

Mainly, the review shows how little is known about prescribing long-term opioids, suggested Dr. Chou, of Oregon Health and Science University, Portland, and lead author of clinical guidelines on chronic opioids for noncancer pain by the American Pain Society and the AAPM. “We really don't have good quality, long-term data on this, which is scary because we're prescribing these medications so much,” Dr. Chou said.

Disclosures: Neither commentator is associated with the Cochrane review. Dr. Chou reported no conflicts of interest. Dr. Fine has been a speaker for Wyeth and an adviser for many pharmaceutical companies that manufacture opioids.

Major Finding: When opioids were used long-term for noncancer pain, 6%-23% of patients stopped taking them due to inefficacy or side effects and 0.3% developed signs of addiction.

Data Source: Cochrane Collaboration review of 26 clinical studies with 4,893 participants.

Disclosures: None were reported in relation to the review.

One of the first systematic reviews of data on long-term use of opioids found weak evidence to support the idea that adults who can take chronic opioids get chronic pain relief, though effects on function or quality of life are unclear.

In a Cochrane Collaboration review of 26 prospective studies with 4,893 participants, 6%-23% of patients (depending on the route of drug administration) dropped out of the clinical trials due to inefficacy or side effects, but those who finished the studies maintained clinically significant reductions in pain for up to 48 months, Meredith Noble and her associates reported.

The review also suggested that opioid abuse or addiction were rare, but acknowledged that the findings are compromised by the limited quantity and poor quality of the studies. Only 7 (0.3%) of 2,613 patients developed signs of addiction or took their medicine inappropriately in the studies that reported those outcomes (Cochrane Database Syst. Rev. 2010 [doi: 10.1002/14651858.CD006605

Most of the studies excluded patients with risk factors for abuse. The low rate of addiction may be generalizable only to patients with no history of abuse or addiction, wrote Ms. Noble, a senior research analyst at the Economic Cycle Research Institute, one of 14 evidence-based practice centers under the Agency for Healthcare Research and Quality. A previous study suggested that addiction or abuse may develop in 3% of patients in all studies of opioid use for chronic pain and in 0.2% of patients in studies that screened out participants with a history of abuse or addiction (Pain Med. 2008;9:444-59).

The evidence of long-term relief of noncancer pain with chronic opioid use was too sparse in the current review to draw firm conclusions, the investigators said.

Among 3,040 patients taking oral opioids, 23% discontinued treatment due to adverse effects and 10% dropped out because of insufficient pain relief. Among 1,628 on transdermal opioids, 12% stopped due to adverse effects and 6% stopped due to insufficient pain relief. Intrathecal pumps delivered opioids in 231 patients who could not find pain relief any other way; of these, 9% stopped due to adverse effects and 8% dropped out due to insufficient pain relief.

One of the studies in the review was a randomized trial comparing two opioids; the other 25 studies were case series or uncontrolled continuations of short-term trials of opioids for noncancer pain. None included comparisons with placebo or nonopioid therapies.

The only other systematic review of opioid use for chronic noncancer pain was a 2008 study by the same investigators.

Solid estimates are lacking for the number of people with chronic noncancer pain who are taking opioids long-term. Two U.S. studies suggest that 0.65% of people with medical insurance use opioids chronically.

However, two pain experts said in interviews they fear clinicians might read too much into the review's limited findings.

The report is “very encouraging, but it's far from the whole story,” Dr. Perry Fine said. Because there are no good substitutes for opioids on the horizon, physicians need to find ways to make long-term opioid use more effective and safe, he said.

Dr. Fine, president of the American Academy of Pain Medicine (AAPM) and professor of anesthesiology at the University of Utah, Salt Lake City, compared current use of long-term opioids for noncancer pain with the use of surgical anesthesia 20-30 years ago when it had significant morbidity and mortality. “That didn't stop us from doing surgical procedures when necessary, but it did motivate research and improvements.”

Primary care internist Dr. Roger Chou said that the 0.3% rate of addiction reported is “a little misleading, because it's based on pretty crummy data.” The review's findings on addiction, pain relief, and adverse events apply to very select groups of patients, not the more complicated cases that raise concerns for physicians considering long-term opioids.

Mainly, the review shows how little is known about prescribing long-term opioids, suggested Dr. Chou, of Oregon Health and Science University, Portland, and lead author of clinical guidelines on chronic opioids for noncancer pain by the American Pain Society and the AAPM. “We really don't have good quality, long-term data on this, which is scary because we're prescribing these medications so much,” Dr. Chou said.

Disclosures: Neither commentator is associated with the Cochrane review. Dr. Chou reported no conflicts of interest. Dr. Fine has been a speaker for Wyeth and an adviser for many pharmaceutical companies that manufacture opioids.