Sherry Boschert

Major Findings: Premeal exenatide injections significantly improved postprandial serum triglyceride levels and endothelial function in patients with impaired glucose tolerance or type 2 diabetes.

Source of Data: Double-blinded crossover trial of 35 patients

Disclosures: The study was funded in part by Amylin Pharmaceuticals and Lilly USA, which jointly market exenatide.

SAN FRANCISCO — A premeal injection of exenatide significantly reduced postprandial serum triglyceride levels compared with placebo in a randomized, double-blinded crossover trial in 35 patients with impaired glucose tolerance or recent-onset type 2 diabetes mellitus.

In 28 patients who also underwent endothelial function tests, postprandial endothelial function was significantly better after premeal exenatide compared with placebo, and after researchers controlled for preinjection endothelial function values, Dr. Gerald Reaven said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

Further analysis suggested that the effects on postprandial triglyceride levels explained about 60% of the effects on endothelial function, added Dr. Reaven, director of the diabetes program at the Veterans Affairs Medical Center, Phoenix.

Investigators are hoping that acute therapy with exenatide or other incretin mimetics may alter metabolic factors to favorably affect endothelial dysfunction, which occurs in the early stages of diabetes. Endothelial dysfunction has been associated with cardiovascular disease, the No. 1 cause of morbidity and mortality in patients with type 2 diabetes. More research is needed to see if acute therapy can improve endothelial function.

Exenatide injection also significantly improved postprandial serum levels of apolipoprotein B48, remnant lipoprotein cholesterol, and remnant lipoprotein triglycerides compared with placebo injection, he reported.

Twenty patients with impaired glucose tolerance and 15 with type 2 diabetes diagnosed within the past 3 years whose hemoglobin A_1c levels were well controlled on diet without medication were randomized to receive a premeal subcutaneous injection of 10 mcg exenatide or saline before eating a calorically dense meal consisting of 45% fat, 40% carbohydrates, and 50% protein. After a 1- to 2-week washout period, the exenatide and saline groups switched therapies. Endothelial function was measured by peripheral arterial tonometry.

Major Findings: Premeal exenatide injections significantly improved postprandial serum triglyceride levels and endothelial function in patients with impaired glucose tolerance or type 2 diabetes.

Source of Data: Double-blinded crossover trial of 35 patients

Disclosures: The study was funded in part by Amylin Pharmaceuticals and Lilly USA, which jointly market exenatide.

SAN FRANCISCO — A premeal injection of exenatide significantly reduced postprandial serum triglyceride levels compared with placebo in a randomized, double-blinded crossover trial in 35 patients with impaired glucose tolerance or recent-onset type 2 diabetes mellitus.

In 28 patients who also underwent endothelial function tests, postprandial endothelial function was significantly better after premeal exenatide compared with placebo, and after researchers controlled for preinjection endothelial function values, Dr. Gerald Reaven said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

Further analysis suggested that the effects on postprandial triglyceride levels explained about 60% of the effects on endothelial function, added Dr. Reaven, director of the diabetes program at the Veterans Affairs Medical Center, Phoenix.

Investigators are hoping that acute therapy with exenatide or other incretin mimetics may alter metabolic factors to favorably affect endothelial dysfunction, which occurs in the early stages of diabetes. Endothelial dysfunction has been associated with cardiovascular disease, the No. 1 cause of morbidity and mortality in patients with type 2 diabetes. More research is needed to see if acute therapy can improve endothelial function.

Exenatide injection also significantly improved postprandial serum levels of apolipoprotein B48, remnant lipoprotein cholesterol, and remnant lipoprotein triglycerides compared with placebo injection, he reported.

Twenty patients with impaired glucose tolerance and 15 with type 2 diabetes diagnosed within the past 3 years whose hemoglobin A_1c levels were well controlled on diet without medication were randomized to receive a premeal subcutaneous injection of 10 mcg exenatide or saline before eating a calorically dense meal consisting of 45% fat, 40% carbohydrates, and 50% protein. After a 1- to 2-week washout period, the exenatide and saline groups switched therapies. Endothelial function was measured by peripheral arterial tonometry.

Major Findings: Premeal exenatide injections significantly improved postprandial serum triglyceride levels and endothelial function in patients with impaired glucose tolerance or type 2 diabetes.

Source of Data: Double-blinded crossover trial of 35 patients

Disclosures: The study was funded in part by Amylin Pharmaceuticals and Lilly USA, which jointly market exenatide.

SAN FRANCISCO — A premeal injection of exenatide significantly reduced postprandial serum triglyceride levels compared with placebo in a randomized, double-blinded crossover trial in 35 patients with impaired glucose tolerance or recent-onset type 2 diabetes mellitus.

In 28 patients who also underwent endothelial function tests, postprandial endothelial function was significantly better after premeal exenatide compared with placebo, and after researchers controlled for preinjection endothelial function values, Dr. Gerald Reaven said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

Further analysis suggested that the effects on postprandial triglyceride levels explained about 60% of the effects on endothelial function, added Dr. Reaven, director of the diabetes program at the Veterans Affairs Medical Center, Phoenix.

Investigators are hoping that acute therapy with exenatide or other incretin mimetics may alter metabolic factors to favorably affect endothelial dysfunction, which occurs in the early stages of diabetes. Endothelial dysfunction has been associated with cardiovascular disease, the No. 1 cause of morbidity and mortality in patients with type 2 diabetes. More research is needed to see if acute therapy can improve endothelial function.

Exenatide injection also significantly improved postprandial serum levels of apolipoprotein B48, remnant lipoprotein cholesterol, and remnant lipoprotein triglycerides compared with placebo injection, he reported.

Twenty patients with impaired glucose tolerance and 15 with type 2 diabetes diagnosed within the past 3 years whose hemoglobin A_1c levels were well controlled on diet without medication were randomized to receive a premeal subcutaneous injection of 10 mcg exenatide or saline before eating a calorically dense meal consisting of 45% fat, 40% carbohydrates, and 50% protein. After a 1- to 2-week washout period, the exenatide and saline groups switched therapies. Endothelial function was measured by peripheral arterial tonometry.

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance with therapy, and took metabolic measurements at the start and the end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy (the more CPAP they got per hours of sleep) was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said. “There's sort of a dose-response relationship between the use of CPAP and changes in metabolic measurements,” he noted.

Among the measures of sleep quality that improved significantly with CPAP therapy, slow-wave sleep activity increased from 59 minutes per night to 72 minutes per night for the cohort as a whole.

The apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than that of women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, Dr. Ehrmann added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment compared with baseline.

If hyperandrogenemia is not a major factor in the development of sleep apnea, perhaps low progesterone and relatively low estradiol levels that are characteristic of PCOS contribute to the higher risk for sleep apnea, Dr. Ehrmann suggested.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep disordered breathing than was age, BMI, or testosterone levels (J. Clin Endocrinol. Metab. 2001;86:517-20).

A separate study found that 29 (56%) of 52 women with PCOS and 4 (19%) of 21 controls had obstructive sleep apnea. After adjustment for the effects of BMI, age, ethnicity, and other factors, the risk for apnea was seven times higher in the PCOS group (J. Clin. Endocrinol. Metab. 2006;91:36-42). In that study, the likelihood of impaired glucose correlated with the severity of sleep apnea.

Dr. Ehrmann and his associates showed that 29 women with PCOS and sleep apnea were significantly more insulin resistant than were 23 women with PCOS but without apnea in a separate study that adjusted for factors including BMI and ethnicity (J. Clin. Endocrinol. Metab. 2008;93:3878-84). Free testosterone levels did not differ between subgroups with no, mild, moderate, or severe apnea.

“It's hard to implicate testosterone as being an important helper for the development of obstructive sleep apnea in women with PCOS,” he said.

Dr. Ehrmann reported having no financial conflicts of interest related to these topics.

CPAP compliance was linked with improved insulin sensitivity in lean and obese women in a small study of women with and without PCOS who had sleep apnea.

Source ©Valerie Garner/Fotolia.com

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance with therapy, and took metabolic measurements at the start and the end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy (the more CPAP they got per hours of sleep) was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said. “There's sort of a dose-response relationship between the use of CPAP and changes in metabolic measurements,” he noted.

Among the measures of sleep quality that improved significantly with CPAP therapy, slow-wave sleep activity increased from 59 minutes per night to 72 minutes per night for the cohort as a whole.

The apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than that of women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, Dr. Ehrmann added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment compared with baseline.

If hyperandrogenemia is not a major factor in the development of sleep apnea, perhaps low progesterone and relatively low estradiol levels that are characteristic of PCOS contribute to the higher risk for sleep apnea, Dr. Ehrmann suggested.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep disordered breathing than was age, BMI, or testosterone levels (J. Clin Endocrinol. Metab. 2001;86:517-20).

A separate study found that 29 (56%) of 52 women with PCOS and 4 (19%) of 21 controls had obstructive sleep apnea. After adjustment for the effects of BMI, age, ethnicity, and other factors, the risk for apnea was seven times higher in the PCOS group (J. Clin. Endocrinol. Metab. 2006;91:36-42). In that study, the likelihood of impaired glucose correlated with the severity of sleep apnea.

Dr. Ehrmann and his associates showed that 29 women with PCOS and sleep apnea were significantly more insulin resistant than were 23 women with PCOS but without apnea in a separate study that adjusted for factors including BMI and ethnicity (J. Clin. Endocrinol. Metab. 2008;93:3878-84). Free testosterone levels did not differ between subgroups with no, mild, moderate, or severe apnea.

“It's hard to implicate testosterone as being an important helper for the development of obstructive sleep apnea in women with PCOS,” he said.

Dr. Ehrmann reported having no financial conflicts of interest related to these topics.

CPAP compliance was linked with improved insulin sensitivity in lean and obese women in a small study of women with and without PCOS who had sleep apnea.

Source ©Valerie Garner/Fotolia.com

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance with therapy, and took metabolic measurements at the start and the end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy (the more CPAP they got per hours of sleep) was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said. “There's sort of a dose-response relationship between the use of CPAP and changes in metabolic measurements,” he noted.

Among the measures of sleep quality that improved significantly with CPAP therapy, slow-wave sleep activity increased from 59 minutes per night to 72 minutes per night for the cohort as a whole.

The apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than that of women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, Dr. Ehrmann added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment compared with baseline.

If hyperandrogenemia is not a major factor in the development of sleep apnea, perhaps low progesterone and relatively low estradiol levels that are characteristic of PCOS contribute to the higher risk for sleep apnea, Dr. Ehrmann suggested.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep disordered breathing than was age, BMI, or testosterone levels (J. Clin Endocrinol. Metab. 2001;86:517-20).

A separate study found that 29 (56%) of 52 women with PCOS and 4 (19%) of 21 controls had obstructive sleep apnea. After adjustment for the effects of BMI, age, ethnicity, and other factors, the risk for apnea was seven times higher in the PCOS group (J. Clin. Endocrinol. Metab. 2006;91:36-42). In that study, the likelihood of impaired glucose correlated with the severity of sleep apnea.

Dr. Ehrmann and his associates showed that 29 women with PCOS and sleep apnea were significantly more insulin resistant than were 23 women with PCOS but without apnea in a separate study that adjusted for factors including BMI and ethnicity (J. Clin. Endocrinol. Metab. 2008;93:3878-84). Free testosterone levels did not differ between subgroups with no, mild, moderate, or severe apnea.

“It's hard to implicate testosterone as being an important helper for the development of obstructive sleep apnea in women with PCOS,” he said.

Dr. Ehrmann reported having no financial conflicts of interest related to these topics.

CPAP compliance was linked with improved insulin sensitivity in lean and obese women in a small study of women with and without PCOS who had sleep apnea.

Source ©Valerie Garner/Fotolia.com

Disclosures: Dr. Caughey disclosed having no potential conflicts of interest related to his presentation.

SAN FRANCISCO — Paternal race may play as big a role in the risk for gestational diabetes as maternal race, according to the results of preliminary studies.

Among white, Asian, and interracial white-Asian couples who delivered babies at Stanford University's Lucile Packard Children's Hospital from 2000 to 2005, the risk for gestational diabetes was 1.6% for 5,575 white couples, 3.4% for 178 couples with a white mother and Asian father, 3.9% for 690 couples with an Asian mother and white father, and 5.7% for Asian couples, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Compared with white couples, the adjusted odds ratio for gestational diabetes was 2.4 in white mother and Asian father couples, 2.6 in Asian mother and white father couples, and 4.7 in Asian couples, the retrospective cohort study found (Am. J. Obstet. Gynecol. 2008;199:385.e1-385.e5).

Some of the difference in risk might be due to sociocultural differences, such as diet, said Dr. Caughey, a study coinvestigator and medical director of the Diabetes and Pregnancy Program at the University of California. However, diet “doesn't seem likely, when you think of the Asian diet versus the Western diet.”

He posited that the association between paternal race and gestational diabetes risk may be influenced by placental hormones that are driven through a genetic association with the father.

Using data from Kaiser Permanente, Dr. Caughey reproduced the finding of an association between paternal race and the risk for gestational diabetes. “I found that in Latinas, the paternal ethnicity is even more important than the maternal ethnicity, which I think is kind of surprising and interesting,” he said. Those findings have not been published.

Maternal race is one of five widely accepted risk factors for gestational diabetes, though there is some controversy. (The other risk factors include age, body mass index, a history of diabetes, and a history of macrosomia.)

Women who have Latina, Native American, south or east Asian, or Pacific Island heritage are at increased risk for gestational diabetes, compared with white women. Older studies that indicated that African American race was associated with gestational diabetes have been called into question because many were conducted in the southern United States, where the prevalence of obesity is high. And the studies did not control for body mass index, Dr. Caughey said.

He and associates looked at Kaiser Permanente data in the San Francisco Bay Area and found no difference in gestational diabetes risk between African Americans and whites. Another recent study in Boston, however, did find an association between African American race and gestational diabetes risk.

It is not clear at this point whether African American race is a risk factor for gestational diabetes. “I think it might be a risk factor, but it's probably very low,” he said.

Race also plays a role in setting screening thresholds for gestational diabetes and deciding which patients to send for diagnostic testing. In general, if the screening threshold is a glucose challenge test result of 140 mg/dL, 14% of women will screen positive (for 80% sensitivity). If the threshold is 130 mg/dL, 23% will screen positive (for 90% sensitivity).

The sensitivity and specificity can vary, however, by ethnicity. Choosing the appropriate screen-positive threshold “really depends on what your goal is,” Dr. Caughey said.

To reach at least 90% sensitivity in all racial groups, the threshold must be lowered from 140 mg/dL to 135 mg/dL. On the other hand, if the goal is a 10% screen-positive rate (specificity), the threshold must go as high as 150 mg/dL for Asians and as low as 135 mg/dL for African Americans, he said. Variations can be seen when stratifying patients by obesity or age, not just race.

Disclosures: Dr. Caughey disclosed having no potential conflicts of interest related to his presentation.

SAN FRANCISCO — Paternal race may play as big a role in the risk for gestational diabetes as maternal race, according to the results of preliminary studies.

Among white, Asian, and interracial white-Asian couples who delivered babies at Stanford University's Lucile Packard Children's Hospital from 2000 to 2005, the risk for gestational diabetes was 1.6% for 5,575 white couples, 3.4% for 178 couples with a white mother and Asian father, 3.9% for 690 couples with an Asian mother and white father, and 5.7% for Asian couples, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Compared with white couples, the adjusted odds ratio for gestational diabetes was 2.4 in white mother and Asian father couples, 2.6 in Asian mother and white father couples, and 4.7 in Asian couples, the retrospective cohort study found (Am. J. Obstet. Gynecol. 2008;199:385.e1-385.e5).

Some of the difference in risk might be due to sociocultural differences, such as diet, said Dr. Caughey, a study coinvestigator and medical director of the Diabetes and Pregnancy Program at the University of California. However, diet “doesn't seem likely, when you think of the Asian diet versus the Western diet.”

He posited that the association between paternal race and gestational diabetes risk may be influenced by placental hormones that are driven through a genetic association with the father.

Using data from Kaiser Permanente, Dr. Caughey reproduced the finding of an association between paternal race and the risk for gestational diabetes. “I found that in Latinas, the paternal ethnicity is even more important than the maternal ethnicity, which I think is kind of surprising and interesting,” he said. Those findings have not been published.

Maternal race is one of five widely accepted risk factors for gestational diabetes, though there is some controversy. (The other risk factors include age, body mass index, a history of diabetes, and a history of macrosomia.)

Women who have Latina, Native American, south or east Asian, or Pacific Island heritage are at increased risk for gestational diabetes, compared with white women. Older studies that indicated that African American race was associated with gestational diabetes have been called into question because many were conducted in the southern United States, where the prevalence of obesity is high. And the studies did not control for body mass index, Dr. Caughey said.

He and associates looked at Kaiser Permanente data in the San Francisco Bay Area and found no difference in gestational diabetes risk between African Americans and whites. Another recent study in Boston, however, did find an association between African American race and gestational diabetes risk.

It is not clear at this point whether African American race is a risk factor for gestational diabetes. “I think it might be a risk factor, but it's probably very low,” he said.

Race also plays a role in setting screening thresholds for gestational diabetes and deciding which patients to send for diagnostic testing. In general, if the screening threshold is a glucose challenge test result of 140 mg/dL, 14% of women will screen positive (for 80% sensitivity). If the threshold is 130 mg/dL, 23% will screen positive (for 90% sensitivity).

The sensitivity and specificity can vary, however, by ethnicity. Choosing the appropriate screen-positive threshold “really depends on what your goal is,” Dr. Caughey said.

To reach at least 90% sensitivity in all racial groups, the threshold must be lowered from 140 mg/dL to 135 mg/dL. On the other hand, if the goal is a 10% screen-positive rate (specificity), the threshold must go as high as 150 mg/dL for Asians and as low as 135 mg/dL for African Americans, he said. Variations can be seen when stratifying patients by obesity or age, not just race.

Disclosures: Dr. Caughey disclosed having no potential conflicts of interest related to his presentation.

SAN FRANCISCO — Paternal race may play as big a role in the risk for gestational diabetes as maternal race, according to the results of preliminary studies.

Among white, Asian, and interracial white-Asian couples who delivered babies at Stanford University's Lucile Packard Children's Hospital from 2000 to 2005, the risk for gestational diabetes was 1.6% for 5,575 white couples, 3.4% for 178 couples with a white mother and Asian father, 3.9% for 690 couples with an Asian mother and white father, and 5.7% for Asian couples, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Compared with white couples, the adjusted odds ratio for gestational diabetes was 2.4 in white mother and Asian father couples, 2.6 in Asian mother and white father couples, and 4.7 in Asian couples, the retrospective cohort study found (Am. J. Obstet. Gynecol. 2008;199:385.e1-385.e5).

Some of the difference in risk might be due to sociocultural differences, such as diet, said Dr. Caughey, a study coinvestigator and medical director of the Diabetes and Pregnancy Program at the University of California. However, diet “doesn't seem likely, when you think of the Asian diet versus the Western diet.”

He posited that the association between paternal race and gestational diabetes risk may be influenced by placental hormones that are driven through a genetic association with the father.

Using data from Kaiser Permanente, Dr. Caughey reproduced the finding of an association between paternal race and the risk for gestational diabetes. “I found that in Latinas, the paternal ethnicity is even more important than the maternal ethnicity, which I think is kind of surprising and interesting,” he said. Those findings have not been published.

Maternal race is one of five widely accepted risk factors for gestational diabetes, though there is some controversy. (The other risk factors include age, body mass index, a history of diabetes, and a history of macrosomia.)

Women who have Latina, Native American, south or east Asian, or Pacific Island heritage are at increased risk for gestational diabetes, compared with white women. Older studies that indicated that African American race was associated with gestational diabetes have been called into question because many were conducted in the southern United States, where the prevalence of obesity is high. And the studies did not control for body mass index, Dr. Caughey said.

He and associates looked at Kaiser Permanente data in the San Francisco Bay Area and found no difference in gestational diabetes risk between African Americans and whites. Another recent study in Boston, however, did find an association between African American race and gestational diabetes risk.

It is not clear at this point whether African American race is a risk factor for gestational diabetes. “I think it might be a risk factor, but it's probably very low,” he said.

Race also plays a role in setting screening thresholds for gestational diabetes and deciding which patients to send for diagnostic testing. In general, if the screening threshold is a glucose challenge test result of 140 mg/dL, 14% of women will screen positive (for 80% sensitivity). If the threshold is 130 mg/dL, 23% will screen positive (for 90% sensitivity).

The sensitivity and specificity can vary, however, by ethnicity. Choosing the appropriate screen-positive threshold “really depends on what your goal is,” Dr. Caughey said.

To reach at least 90% sensitivity in all racial groups, the threshold must be lowered from 140 mg/dL to 135 mg/dL. On the other hand, if the goal is a 10% screen-positive rate (specificity), the threshold must go as high as 150 mg/dL for Asians and as low as 135 mg/dL for African Americans, he said. Variations can be seen when stratifying patients by obesity or age, not just race.

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

The investigators were surprised to find statistically similar rates of malnutrition in 264 adults with inflammatory bowel disease (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 with low serum levels of iron (17% in adults and 22% in children) or folate (2% vs. 3%, respectively).

Participants had 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. Active disease did not increase the risk of malnutrition in the other subgroups.

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. Malnutrition was defined in patients younger than 20 years as a body mass index z score for age below two standard deviations. In adults aged 20–64 years, a BMI less than 18.5 kg/m

Dr. Marcil reported having 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 has shown.

The investigators were surprised to find statistically similar rates of malnutrition in 264 adults with inflammatory bowel disease (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 with low serum levels of iron (17% in adults and 22% in children) or folate (2% vs. 3%, respectively).

Participants had 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. Active disease did not increase the risk of malnutrition in the other subgroups.

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. Malnutrition was defined in patients younger than 20 years as a body mass index z score for age below two standard deviations. In adults aged 20–64 years, a BMI less than 18.5 kg/m

Dr. Marcil reported having 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 has shown.

The investigators were surprised to find statistically similar rates of malnutrition in 264 adults with inflammatory bowel disease (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 with low serum levels of iron (17% in adults and 22% in children) or folate (2% vs. 3%, respectively).

Participants had 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. Active disease did not increase the risk of malnutrition in the other subgroups.

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. Malnutrition was defined in patients younger than 20 years as a body mass index z score for age below two standard deviations. In adults aged 20–64 years, a BMI less than 18.5 kg/m

Dr. Marcil reported having no conflicts of interest.

SAN DIEGO — Microvesicular steatosis may be more common in patients with nonalcoholic fatty liver disease than previously thought and is associated with markers of severe disease, a study of 1,022 biopsies suggests.

Ten percent of the liver biopsies from adult patients with nonalcoholic fatty liver disease (NAFLD) showed microvesicular steatosis when reviewed by a pathology committee for the study, Dr. Sweta R. Tandra and her associates reported at the annual meeting of the American College of Gastroenterology.

Previously, microvesicular steatosis was thought to be rare in patients with NAFLD, which is more typically associated with macrovesicular steatosis, said Dr. Tandra of Indiana University, Indianapolis. The significance of the presence of microvesicular steatosis has been unclear.

The investigators found microvesicular steatosis in 102 (10%) of the biopsies, which came from patients with an average age of 50 years and a mean body mass index of 35 kg/m

The presence of microvesicular steatosis was significantly associated with histologic indices that denote severe disease, including higher grades of macrovesicular steatosis, advanced fibrosis, ballooned hepatocytes, megamitochondria, higher NAFLD activity scores, and a diagnosis of nonalcoholic steatohepatitis. The findings were based on a multivariate analysis that adjusted for the influence of age, sex, race, body mass index, and the presence of diabetes.

The presence of macrovesicular steatosis increased the likelihood of finding microvesicular steatosis two- to sixfold. Also, patients with fibrosis were two to six times more likely to have microvesicular steatosis than were patients without fibrosis. Microvesicular steatosis was three to four times more likely in the presence of ballooning and five times more likely in the presence of megamitochondria, two markers of cell injury.

No associations were seen between microvesicular steatosis and lobular inflammation or levels of AST or ALT.

Biopsies were obtained from a consortium of eight clinical research centers and one data coordinating center sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

On histology, macrovesicular steatosis is defined by a single, large vacuole of fat that fills up the hepatocyte and displaces the nucleus to the periphery of the cell. In comparison, the presence of multiple small intracellular lipid droplets with an undisplaced nucleus generally defines microvesicular steatosis, which has been thought to result from impaired mitochondrial beta-oxidation of fatty acids.

“As microvesicular steatosis generally indicates mitochondrial dysfunction, our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis,” said Dr. Tandra, who reported having no conflicts of interest.

'Our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis.'

Source DR. TANDRA

SAN DIEGO — Microvesicular steatosis may be more common in patients with nonalcoholic fatty liver disease than previously thought and is associated with markers of severe disease, a study of 1,022 biopsies suggests.

Ten percent of the liver biopsies from adult patients with nonalcoholic fatty liver disease (NAFLD) showed microvesicular steatosis when reviewed by a pathology committee for the study, Dr. Sweta R. Tandra and her associates reported at the annual meeting of the American College of Gastroenterology.

Previously, microvesicular steatosis was thought to be rare in patients with NAFLD, which is more typically associated with macrovesicular steatosis, said Dr. Tandra of Indiana University, Indianapolis. The significance of the presence of microvesicular steatosis has been unclear.

The investigators found microvesicular steatosis in 102 (10%) of the biopsies, which came from patients with an average age of 50 years and a mean body mass index of 35 kg/m

The presence of microvesicular steatosis was significantly associated with histologic indices that denote severe disease, including higher grades of macrovesicular steatosis, advanced fibrosis, ballooned hepatocytes, megamitochondria, higher NAFLD activity scores, and a diagnosis of nonalcoholic steatohepatitis. The findings were based on a multivariate analysis that adjusted for the influence of age, sex, race, body mass index, and the presence of diabetes.

The presence of macrovesicular steatosis increased the likelihood of finding microvesicular steatosis two- to sixfold. Also, patients with fibrosis were two to six times more likely to have microvesicular steatosis than were patients without fibrosis. Microvesicular steatosis was three to four times more likely in the presence of ballooning and five times more likely in the presence of megamitochondria, two markers of cell injury.

No associations were seen between microvesicular steatosis and lobular inflammation or levels of AST or ALT.

Biopsies were obtained from a consortium of eight clinical research centers and one data coordinating center sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

On histology, macrovesicular steatosis is defined by a single, large vacuole of fat that fills up the hepatocyte and displaces the nucleus to the periphery of the cell. In comparison, the presence of multiple small intracellular lipid droplets with an undisplaced nucleus generally defines microvesicular steatosis, which has been thought to result from impaired mitochondrial beta-oxidation of fatty acids.

“As microvesicular steatosis generally indicates mitochondrial dysfunction, our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis,” said Dr. Tandra, who reported having no conflicts of interest.

'Our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis.'

Source DR. TANDRA

SAN DIEGO — Microvesicular steatosis may be more common in patients with nonalcoholic fatty liver disease than previously thought and is associated with markers of severe disease, a study of 1,022 biopsies suggests.

Ten percent of the liver biopsies from adult patients with nonalcoholic fatty liver disease (NAFLD) showed microvesicular steatosis when reviewed by a pathology committee for the study, Dr. Sweta R. Tandra and her associates reported at the annual meeting of the American College of Gastroenterology.

Previously, microvesicular steatosis was thought to be rare in patients with NAFLD, which is more typically associated with macrovesicular steatosis, said Dr. Tandra of Indiana University, Indianapolis. The significance of the presence of microvesicular steatosis has been unclear.

The investigators found microvesicular steatosis in 102 (10%) of the biopsies, which came from patients with an average age of 50 years and a mean body mass index of 35 kg/m

The presence of microvesicular steatosis was significantly associated with histologic indices that denote severe disease, including higher grades of macrovesicular steatosis, advanced fibrosis, ballooned hepatocytes, megamitochondria, higher NAFLD activity scores, and a diagnosis of nonalcoholic steatohepatitis. The findings were based on a multivariate analysis that adjusted for the influence of age, sex, race, body mass index, and the presence of diabetes.

The presence of macrovesicular steatosis increased the likelihood of finding microvesicular steatosis two- to sixfold. Also, patients with fibrosis were two to six times more likely to have microvesicular steatosis than were patients without fibrosis. Microvesicular steatosis was three to four times more likely in the presence of ballooning and five times more likely in the presence of megamitochondria, two markers of cell injury.

No associations were seen between microvesicular steatosis and lobular inflammation or levels of AST or ALT.

Biopsies were obtained from a consortium of eight clinical research centers and one data coordinating center sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

On histology, macrovesicular steatosis is defined by a single, large vacuole of fat that fills up the hepatocyte and displaces the nucleus to the periphery of the cell. In comparison, the presence of multiple small intracellular lipid droplets with an undisplaced nucleus generally defines microvesicular steatosis, which has been thought to result from impaired mitochondrial beta-oxidation of fatty acids.

“As microvesicular steatosis generally indicates mitochondrial dysfunction, our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis,” said Dr. Tandra, who reported having no conflicts of interest.

'Our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis.'

Source DR. TANDRA

SAN FRANCISCO — Antiretroviral therapy has allowed many HIV-infected people to live long enough to grow old, yet their immune systems seem to age rapidly for their chronologic age, a factor that appears to be contributing to increased risks for non-HIV diseases of aging in middle-aged patients, according to several speakers at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

“There are striking similarities between the immune systems of some of our patients in their 50s and [those of] their parents,” said Dr. Steven G. Deeks, professor of medicine at the university.

In 2007, 28% of people living with HIV were aged 50 years or older; that proportion will grow to 50% by 2015, Dr. Richard Brooks, also of the university, said in a separate presentation.

Also at the meeting, Dr. Toby Maurer reported that her clinic is seeing more HIV-infected patients with skin diseases associated with aging, including disseminated herpes zoster and indolent Kaposi's sarcoma, despite relatively healthy CD4 counts ranging between 300 and 700 cells/mm

Disseminated zoster is “very unusual with a CD4 count of 350 cells/mm

The Kaposi's sarcoma cases are not the aggressive variety seen 20 years ago in HIV-infected patients, she said, but are the type typically found in older Mediterranean men.

To preserve immune function, Dr. Deeks advocates starting highly active antiretroviral therapy (HAART) in any HIV-infected patient who is motivated to begin treatment—a more aggressive approach than called for in treatment guidelines.

HAART reduces but does not eliminate T-cell activation and inflammation. Persistent, residual inflammation while on HAART is more extensive when patients start therapy at CD4 counts less than 200 copies/mm

Previous attempts to reduce HIV-associated immunosenescence and inflammation through the use of prednisone, hydroxyurea, cyclosporin, or mycophenolic acid were “like treating a subtle problem with sledgehammers,” Dr. Deeks said.

“We need to reduce inflammation in a safe way” through the use of statins, aspirin, exercise, omega-3 fatty acids, vitamins, and immunomodulators, he said. Newer strategies could include investigational drugs that enhance recovery of CD4 cells or that fully eradicate the subtle levels of persistent or replicating virus.

An “overwhelming amount of data” show that even patients with undetectable virus and increased CD4 counts on HAART are more likely than people without HIV to develop heart disease, non-AIDS cancer, bone disease and fractures, left ventricular dysfunction, liver or kidney failure, and frailty, Dr. Deeks said.

After controlling for the effects of other factors, including lipids or hypertension, HIV-infected patients have a 75% higher risk for cardiovascular events than do uninfected people, several studies suggest.

Dr. Brooks noted that frailty was 11 times more common in HIV-positive men, compared with HIV-negative men, in one study (J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:1279–86). HIV infection of 4 years' duration or less conferred a risk for frailty in a 55-year-old man that compared with risks for a 65-year-old HIV-negative man, “confirming our impression that HIV-positive men are aging faster than their HIV-negative counterparts,” said Dr. Brooks.

To help HIV-infected patients stay healthy longer, he advised focusing on modification of traditional risk factors for non-HIV comorbidities of aging—smoking, hypertension, dyslipidemia, weight gain, diet, and exercise.

When possible, avoid HIV medications that can exacerbate illnesses associated with aging and check for drug-drug interactions, he added. Older protease inhibitors and zidovudine increase the risk for insulin resistance. Abacavir, didanosine, and protease inhibitors increase risk for cardiovascular disease. Zidovudine, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors increase risk for dyslipidemia.

Dr. Deeks has been an adviser to GlaxoSmithKline and received research funds from Pfizer, Merck, Gilead, and Bristol-Myers Squibb. Dr. Maurer and Dr. Brooks reported having no conflicts of interest.

SAN FRANCISCO — Antiretroviral therapy has allowed many HIV-infected people to live long enough to grow old, yet their immune systems seem to age rapidly for their chronologic age, a factor that appears to be contributing to increased risks for non-HIV diseases of aging in middle-aged patients, according to several speakers at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

“There are striking similarities between the immune systems of some of our patients in their 50s and [those of] their parents,” said Dr. Steven G. Deeks, professor of medicine at the university.

In 2007, 28% of people living with HIV were aged 50 years or older; that proportion will grow to 50% by 2015, Dr. Richard Brooks, also of the university, said in a separate presentation.

Also at the meeting, Dr. Toby Maurer reported that her clinic is seeing more HIV-infected patients with skin diseases associated with aging, including disseminated herpes zoster and indolent Kaposi's sarcoma, despite relatively healthy CD4 counts ranging between 300 and 700 cells/mm

Disseminated zoster is “very unusual with a CD4 count of 350 cells/mm

The Kaposi's sarcoma cases are not the aggressive variety seen 20 years ago in HIV-infected patients, she said, but are the type typically found in older Mediterranean men.

To preserve immune function, Dr. Deeks advocates starting highly active antiretroviral therapy (HAART) in any HIV-infected patient who is motivated to begin treatment—a more aggressive approach than called for in treatment guidelines.

HAART reduces but does not eliminate T-cell activation and inflammation. Persistent, residual inflammation while on HAART is more extensive when patients start therapy at CD4 counts less than 200 copies/mm

Previous attempts to reduce HIV-associated immunosenescence and inflammation through the use of prednisone, hydroxyurea, cyclosporin, or mycophenolic acid were “like treating a subtle problem with sledgehammers,” Dr. Deeks said.

“We need to reduce inflammation in a safe way” through the use of statins, aspirin, exercise, omega-3 fatty acids, vitamins, and immunomodulators, he said. Newer strategies could include investigational drugs that enhance recovery of CD4 cells or that fully eradicate the subtle levels of persistent or replicating virus.

An “overwhelming amount of data” show that even patients with undetectable virus and increased CD4 counts on HAART are more likely than people without HIV to develop heart disease, non-AIDS cancer, bone disease and fractures, left ventricular dysfunction, liver or kidney failure, and frailty, Dr. Deeks said.

After controlling for the effects of other factors, including lipids or hypertension, HIV-infected patients have a 75% higher risk for cardiovascular events than do uninfected people, several studies suggest.

Dr. Brooks noted that frailty was 11 times more common in HIV-positive men, compared with HIV-negative men, in one study (J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:1279–86). HIV infection of 4 years' duration or less conferred a risk for frailty in a 55-year-old man that compared with risks for a 65-year-old HIV-negative man, “confirming our impression that HIV-positive men are aging faster than their HIV-negative counterparts,” said Dr. Brooks.

To help HIV-infected patients stay healthy longer, he advised focusing on modification of traditional risk factors for non-HIV comorbidities of aging—smoking, hypertension, dyslipidemia, weight gain, diet, and exercise.

When possible, avoid HIV medications that can exacerbate illnesses associated with aging and check for drug-drug interactions, he added. Older protease inhibitors and zidovudine increase the risk for insulin resistance. Abacavir, didanosine, and protease inhibitors increase risk for cardiovascular disease. Zidovudine, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors increase risk for dyslipidemia.

Dr. Deeks has been an adviser to GlaxoSmithKline and received research funds from Pfizer, Merck, Gilead, and Bristol-Myers Squibb. Dr. Maurer and Dr. Brooks reported having no conflicts of interest.

SAN FRANCISCO — Antiretroviral therapy has allowed many HIV-infected people to live long enough to grow old, yet their immune systems seem to age rapidly for their chronologic age, a factor that appears to be contributing to increased risks for non-HIV diseases of aging in middle-aged patients, according to several speakers at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

“There are striking similarities between the immune systems of some of our patients in their 50s and [those of] their parents,” said Dr. Steven G. Deeks, professor of medicine at the university.

In 2007, 28% of people living with HIV were aged 50 years or older; that proportion will grow to 50% by 2015, Dr. Richard Brooks, also of the university, said in a separate presentation.

Also at the meeting, Dr. Toby Maurer reported that her clinic is seeing more HIV-infected patients with skin diseases associated with aging, including disseminated herpes zoster and indolent Kaposi's sarcoma, despite relatively healthy CD4 counts ranging between 300 and 700 cells/mm

Disseminated zoster is “very unusual with a CD4 count of 350 cells/mm

The Kaposi's sarcoma cases are not the aggressive variety seen 20 years ago in HIV-infected patients, she said, but are the type typically found in older Mediterranean men.

To preserve immune function, Dr. Deeks advocates starting highly active antiretroviral therapy (HAART) in any HIV-infected patient who is motivated to begin treatment—a more aggressive approach than called for in treatment guidelines.

HAART reduces but does not eliminate T-cell activation and inflammation. Persistent, residual inflammation while on HAART is more extensive when patients start therapy at CD4 counts less than 200 copies/mm

Previous attempts to reduce HIV-associated immunosenescence and inflammation through the use of prednisone, hydroxyurea, cyclosporin, or mycophenolic acid were “like treating a subtle problem with sledgehammers,” Dr. Deeks said.

“We need to reduce inflammation in a safe way” through the use of statins, aspirin, exercise, omega-3 fatty acids, vitamins, and immunomodulators, he said. Newer strategies could include investigational drugs that enhance recovery of CD4 cells or that fully eradicate the subtle levels of persistent or replicating virus.

An “overwhelming amount of data” show that even patients with undetectable virus and increased CD4 counts on HAART are more likely than people without HIV to develop heart disease, non-AIDS cancer, bone disease and fractures, left ventricular dysfunction, liver or kidney failure, and frailty, Dr. Deeks said.

After controlling for the effects of other factors, including lipids or hypertension, HIV-infected patients have a 75% higher risk for cardiovascular events than do uninfected people, several studies suggest.

Dr. Brooks noted that frailty was 11 times more common in HIV-positive men, compared with HIV-negative men, in one study (J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:1279–86). HIV infection of 4 years' duration or less conferred a risk for frailty in a 55-year-old man that compared with risks for a 65-year-old HIV-negative man, “confirming our impression that HIV-positive men are aging faster than their HIV-negative counterparts,” said Dr. Brooks.

To help HIV-infected patients stay healthy longer, he advised focusing on modification of traditional risk factors for non-HIV comorbidities of aging—smoking, hypertension, dyslipidemia, weight gain, diet, and exercise.

When possible, avoid HIV medications that can exacerbate illnesses associated with aging and check for drug-drug interactions, he added. Older protease inhibitors and zidovudine increase the risk for insulin resistance. Abacavir, didanosine, and protease inhibitors increase risk for cardiovascular disease. Zidovudine, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors increase risk for dyslipidemia.

Dr. Deeks has been an adviser to GlaxoSmithKline and received research funds from Pfizer, Merck, Gilead, and Bristol-Myers Squibb. Dr. Maurer and Dr. Brooks reported having no conflicts of interest.

SAN FRANCISCO — Treating metabolic abnormalities in patients with schizophrenia may be a better way to deal with insulin resistance or dyslipidemia than switching antipsychotics, Dr. Sun H. Kim suggests.

Second-generation antipsychotics can cause weight gain, and some data suggest that these drugs may have direct effects on insulin resistance and the risk for diabetes, independent of body mass index. The psychiatric literature has focused on managing patients with schizophrenia who develop metabolic abnormalities by switching second-generation antipsychotics, because some drugs are associated with less weight gain than others.

The few studies on the topic, however, suggest that this strategy doesn't work and can psychiatrically harm patients who were stable on medication before switching, she said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

“Switching isn't likely to resolve their existing metabolic abnormalities,” said Dr. Kim of Stanford (Calif.) University. “I think there should be more focus on directly treating the abnormalities.”

A pilot study by Dr. Kim and her associates included 15 young outpatients with schizophrenia and a fasting glucose of 126 mg/dL or lower who tried to switch therapy after gaining more than 10 kg on a second-generation antipsychotic medication. They were obese (with a mean BMI of 34 mg/kg

Oral glucose tolerance tests at baseline showed that 47% had diabetes (20%) or impaired glucose tolerance (27%). The mean fasting glucose was 97 mg/dL, and the mean 2-hour glucose was 150 mg/dL. “Based on our measurements, three quarters of them were highly insulin resistant,” Dr. Kim said. The patients had been taking quetiapine, olanzapine, risperidone, ziprasidone, or clozapine.

When they tried to switch to the antipsychotic aripiprazole, five patients (33%) could not tolerate the switch psychiatrically. After 4 months on aripiprazole, 3 of the other 10 patients had lost 6–13 kg, 1 patient had no change in weight, and 6 patients gained 1–11 kg. As a group, the mean weight did not change significantly. The weight changes “didn't have a tremendous impact on insulin resistance,” she said, and no significant changes were seen in mean BMI, waist circumference, total triglycerides, HDL or LDL cholesterol levels, plasma glucose levels, or steady state plasma glucose (J. Clin. Psychopharmacol. 2007;27:365–8).

A larger, multicenter study by other investigators of 173 patients with schizophrenia or schizoaffective disorder who were being treated with olanzapine randomized them to continue on olanzapine (85 patients) or switch to aripiprazole (88 patients). The cohort had a mean BMI of 27 kg/m

Dropout rates were high in both groups—36% on aripiprazole and 26% on olanzapine. By the end of the 16-week study, mean weight had increased by 1.4 kg in the olanzapine group and decreased by 1.8 kg in the aripiprazole group—not an impressive change, Dr. Kim said. A slight benefit in triglyceride levels was seen in the aripiprazole group (a 14% decrease), compared with the olanzapine group (a 5% increase), but there were no significant changes in fasting glucose or insulin resistance. The Clinical Global Impressions–Improvement scores were statistically better with olanzapine than with aripiprazole, she added (J. Clin. Psychiatry 2008;69:1046–56).

“You have to weigh the risks and benefits of switching someone who is stable psychiatrically on one of these medications,” said Dr. Kim, who has received research funding from Eli Lilly & Co.

SAN FRANCISCO — Treating metabolic abnormalities in patients with schizophrenia may be a better way to deal with insulin resistance or dyslipidemia than switching antipsychotics, Dr. Sun H. Kim suggests.

Second-generation antipsychotics can cause weight gain, and some data suggest that these drugs may have direct effects on insulin resistance and the risk for diabetes, independent of body mass index. The psychiatric literature has focused on managing patients with schizophrenia who develop metabolic abnormalities by switching second-generation antipsychotics, because some drugs are associated with less weight gain than others.

The few studies on the topic, however, suggest that this strategy doesn't work and can psychiatrically harm patients who were stable on medication before switching, she said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

“Switching isn't likely to resolve their existing metabolic abnormalities,” said Dr. Kim of Stanford (Calif.) University. “I think there should be more focus on directly treating the abnormalities.”

A pilot study by Dr. Kim and her associates included 15 young outpatients with schizophrenia and a fasting glucose of 126 mg/dL or lower who tried to switch therapy after gaining more than 10 kg on a second-generation antipsychotic medication. They were obese (with a mean BMI of 34 mg/kg

Oral glucose tolerance tests at baseline showed that 47% had diabetes (20%) or impaired glucose tolerance (27%). The mean fasting glucose was 97 mg/dL, and the mean 2-hour glucose was 150 mg/dL. “Based on our measurements, three quarters of them were highly insulin resistant,” Dr. Kim said. The patients had been taking quetiapine, olanzapine, risperidone, ziprasidone, or clozapine.

When they tried to switch to the antipsychotic aripiprazole, five patients (33%) could not tolerate the switch psychiatrically. After 4 months on aripiprazole, 3 of the other 10 patients had lost 6–13 kg, 1 patient had no change in weight, and 6 patients gained 1–11 kg. As a group, the mean weight did not change significantly. The weight changes “didn't have a tremendous impact on insulin resistance,” she said, and no significant changes were seen in mean BMI, waist circumference, total triglycerides, HDL or LDL cholesterol levels, plasma glucose levels, or steady state plasma glucose (J. Clin. Psychopharmacol. 2007;27:365–8).

A larger, multicenter study by other investigators of 173 patients with schizophrenia or schizoaffective disorder who were being treated with olanzapine randomized them to continue on olanzapine (85 patients) or switch to aripiprazole (88 patients). The cohort had a mean BMI of 27 kg/m

Dropout rates were high in both groups—36% on aripiprazole and 26% on olanzapine. By the end of the 16-week study, mean weight had increased by 1.4 kg in the olanzapine group and decreased by 1.8 kg in the aripiprazole group—not an impressive change, Dr. Kim said. A slight benefit in triglyceride levels was seen in the aripiprazole group (a 14% decrease), compared with the olanzapine group (a 5% increase), but there were no significant changes in fasting glucose or insulin resistance. The Clinical Global Impressions–Improvement scores were statistically better with olanzapine than with aripiprazole, she added (J. Clin. Psychiatry 2008;69:1046–56).

“You have to weigh the risks and benefits of switching someone who is stable psychiatrically on one of these medications,” said Dr. Kim, who has received research funding from Eli Lilly & Co.

SAN FRANCISCO — Treating metabolic abnormalities in patients with schizophrenia may be a better way to deal with insulin resistance or dyslipidemia than switching antipsychotics, Dr. Sun H. Kim suggests.

Second-generation antipsychotics can cause weight gain, and some data suggest that these drugs may have direct effects on insulin resistance and the risk for diabetes, independent of body mass index. The psychiatric literature has focused on managing patients with schizophrenia who develop metabolic abnormalities by switching second-generation antipsychotics, because some drugs are associated with less weight gain than others.

The few studies on the topic, however, suggest that this strategy doesn't work and can psychiatrically harm patients who were stable on medication before switching, she said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

“Switching isn't likely to resolve their existing metabolic abnormalities,” said Dr. Kim of Stanford (Calif.) University. “I think there should be more focus on directly treating the abnormalities.”

A pilot study by Dr. Kim and her associates included 15 young outpatients with schizophrenia and a fasting glucose of 126 mg/dL or lower who tried to switch therapy after gaining more than 10 kg on a second-generation antipsychotic medication. They were obese (with a mean BMI of 34 mg/kg

Oral glucose tolerance tests at baseline showed that 47% had diabetes (20%) or impaired glucose tolerance (27%). The mean fasting glucose was 97 mg/dL, and the mean 2-hour glucose was 150 mg/dL. “Based on our measurements, three quarters of them were highly insulin resistant,” Dr. Kim said. The patients had been taking quetiapine, olanzapine, risperidone, ziprasidone, or clozapine.

When they tried to switch to the antipsychotic aripiprazole, five patients (33%) could not tolerate the switch psychiatrically. After 4 months on aripiprazole, 3 of the other 10 patients had lost 6–13 kg, 1 patient had no change in weight, and 6 patients gained 1–11 kg. As a group, the mean weight did not change significantly. The weight changes “didn't have a tremendous impact on insulin resistance,” she said, and no significant changes were seen in mean BMI, waist circumference, total triglycerides, HDL or LDL cholesterol levels, plasma glucose levels, or steady state plasma glucose (J. Clin. Psychopharmacol. 2007;27:365–8).

A larger, multicenter study by other investigators of 173 patients with schizophrenia or schizoaffective disorder who were being treated with olanzapine randomized them to continue on olanzapine (85 patients) or switch to aripiprazole (88 patients). The cohort had a mean BMI of 27 kg/m

Dropout rates were high in both groups—36% on aripiprazole and 26% on olanzapine. By the end of the 16-week study, mean weight had increased by 1.4 kg in the olanzapine group and decreased by 1.8 kg in the aripiprazole group—not an impressive change, Dr. Kim said. A slight benefit in triglyceride levels was seen in the aripiprazole group (a 14% decrease), compared with the olanzapine group (a 5% increase), but there were no significant changes in fasting glucose or insulin resistance. The Clinical Global Impressions–Improvement scores were statistically better with olanzapine than with aripiprazole, she added (J. Clin. Psychiatry 2008;69:1046–56).

“You have to weigh the risks and benefits of switching someone who is stable psychiatrically on one of these medications,” said Dr. Kim, who has received research funding from Eli Lilly & Co.

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance with therapy, and took metabolic measurements at the start and the end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy (the more CPAP they got per hours of sleep) was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said.

Among the measures of sleep quality that improved significantly with CPAP therapy, slow-wave sleep activity increased from 59 minutes per night to 72 minutes per night for the cohort as a whole. The apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, Dr. Ehrmann added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment compared with baseline.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep disordered breathing than was age, BMI, or testosterone levels (J. Clin Endocrinol. Metab. 2001;86:517–20).

Dr. Ehrmann reported having no conflicts of interest related to these topics.

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance with therapy, and took metabolic measurements at the start and the end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy (the more CPAP they got per hours of sleep) was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said.

Among the measures of sleep quality that improved significantly with CPAP therapy, slow-wave sleep activity increased from 59 minutes per night to 72 minutes per night for the cohort as a whole. The apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, Dr. Ehrmann added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment compared with baseline.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep disordered breathing than was age, BMI, or testosterone levels (J. Clin Endocrinol. Metab. 2001;86:517–20).

Dr. Ehrmann reported having no conflicts of interest related to these topics.

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance with therapy, and took metabolic measurements at the start and the end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy (the more CPAP they got per hours of sleep) was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said.

Among the measures of sleep quality that improved significantly with CPAP therapy, slow-wave sleep activity increased from 59 minutes per night to 72 minutes per night for the cohort as a whole. The apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, Dr. Ehrmann added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment compared with baseline.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep disordered breathing than was age, BMI, or testosterone levels (J. Clin Endocrinol. Metab. 2001;86:517–20).

Dr. Ehrmann reported having no conflicts of interest related to these topics.

SAN DIEGO — Prophylactic use of a proton pump inhibitor plus clopidogrel after percutaneous coronary revascularization was associated with significantly greater risk for cardiovascular events, compared with taking clopidogrel alone, a small retrospective study found.

After percutaneous coronary intervention (PCI), 40 (56%) of 72 patients discharged on concomitant clopidogrel and proton pump inhibitor (PPI) therapy developed major adverse coronary events over a mean follow-up of 50 months, compared with 92 (38%) of 243 patients discharged on clopidogrel alone, Dr. Ekta Gupta and her associates reported at the annual meeting of the American College of Gastroenterology.

After researchers adjusted for baseline characteristics including the type of stent, patients in the combination-therapy group had a 95% excess risk for major adverse coronary events, said Dr. Gupta of the University of Arkansas, Little Rock. “Our study suggests that 'routine' use of prophylactic PPIs to prevent gastrointestinal bleeding should be avoided.”

The adverse coronary events studied included cardiac or noncardiac death, MI, and target vessel failure (which was defined as a composite of cardiac death, MI, or target vessel revascularization).

Most patients who got a PPI used rabeprazole, with a minority getting omeprazole or lansoprazole. The study excluded patients who received pantoprazole or esomeprazole because previous studies found no association between these two drugs and an impaired response to clopidogrel seen with the other PPIs, suggesting that the adverse PPI-clopidogrel interaction may not apply to the whole class of drugs, she said.

If a PPI needs to be used after PCI, it may be preferable to use esomeprazole or pantoprazole, Dr. Gupta suggested. Alternatively, clinicians may want to consider separating the dosing of clopidogrel and the PPI to avoid potential drug-drug interaction.

Dr. Gupta had no conflicts of interest related to this study.

SAN DIEGO — Prophylactic use of a proton pump inhibitor plus clopidogrel after percutaneous coronary revascularization was associated with significantly greater risk for cardiovascular events, compared with taking clopidogrel alone, a small retrospective study found.

After percutaneous coronary intervention (PCI), 40 (56%) of 72 patients discharged on concomitant clopidogrel and proton pump inhibitor (PPI) therapy developed major adverse coronary events over a mean follow-up of 50 months, compared with 92 (38%) of 243 patients discharged on clopidogrel alone, Dr. Ekta Gupta and her associates reported at the annual meeting of the American College of Gastroenterology.

After researchers adjusted for baseline characteristics including the type of stent, patients in the combination-therapy group had a 95% excess risk for major adverse coronary events, said Dr. Gupta of the University of Arkansas, Little Rock. “Our study suggests that 'routine' use of prophylactic PPIs to prevent gastrointestinal bleeding should be avoided.”

The adverse coronary events studied included cardiac or noncardiac death, MI, and target vessel failure (which was defined as a composite of cardiac death, MI, or target vessel revascularization).

Most patients who got a PPI used rabeprazole, with a minority getting omeprazole or lansoprazole. The study excluded patients who received pantoprazole or esomeprazole because previous studies found no association between these two drugs and an impaired response to clopidogrel seen with the other PPIs, suggesting that the adverse PPI-clopidogrel interaction may not apply to the whole class of drugs, she said.

If a PPI needs to be used after PCI, it may be preferable to use esomeprazole or pantoprazole, Dr. Gupta suggested. Alternatively, clinicians may want to consider separating the dosing of clopidogrel and the PPI to avoid potential drug-drug interaction.

Dr. Gupta had no conflicts of interest related to this study.

SAN DIEGO — Prophylactic use of a proton pump inhibitor plus clopidogrel after percutaneous coronary revascularization was associated with significantly greater risk for cardiovascular events, compared with taking clopidogrel alone, a small retrospective study found.

After percutaneous coronary intervention (PCI), 40 (56%) of 72 patients discharged on concomitant clopidogrel and proton pump inhibitor (PPI) therapy developed major adverse coronary events over a mean follow-up of 50 months, compared with 92 (38%) of 243 patients discharged on clopidogrel alone, Dr. Ekta Gupta and her associates reported at the annual meeting of the American College of Gastroenterology.

After researchers adjusted for baseline characteristics including the type of stent, patients in the combination-therapy group had a 95% excess risk for major adverse coronary events, said Dr. Gupta of the University of Arkansas, Little Rock. “Our study suggests that 'routine' use of prophylactic PPIs to prevent gastrointestinal bleeding should be avoided.”

The adverse coronary events studied included cardiac or noncardiac death, MI, and target vessel failure (which was defined as a composite of cardiac death, MI, or target vessel revascularization).

Most patients who got a PPI used rabeprazole, with a minority getting omeprazole or lansoprazole. The study excluded patients who received pantoprazole or esomeprazole because previous studies found no association between these two drugs and an impaired response to clopidogrel seen with the other PPIs, suggesting that the adverse PPI-clopidogrel interaction may not apply to the whole class of drugs, she said.

If a PPI needs to be used after PCI, it may be preferable to use esomeprazole or pantoprazole, Dr. Gupta suggested. Alternatively, clinicians may want to consider separating the dosing of clopidogrel and the PPI to avoid potential drug-drug interaction.

Dr. Gupta had no conflicts of interest related to this study.

SAN DIEGO — Split-dose bowel preparation was found to be superior to a conventional whole-dose bowel cleansing regimen in a randomized, prospective study of 43 hospital inpatients.

The 22 patients who were randomized to a split-dose regimen of polyethylene glycol electrolyte solution (GoLYTELY) to purge the colon reported less abdominal pain or cramping, were more likely to be willing to undergo the procedure again, and achieved better colon cleansing, compared with 21 patients in the whole-dose group. These differences between groups were statistically significant, Dr. Roxanne Lim and her associates reported at the annual meeting of the American College of Gastroenterology.

In Dr. Lim's study, the indications for colonoscopy in these hospitalized patients included GI bleeding, abdominal pain, anemia, diarrhea, or an abnormal result on abdominal imaging.

The patients in the split-dose group received 2 L of GoLYTELY beginning at 5 p.m. the evening before the colonoscopy, and then another 2 L beginning at 5 a.m. the morning of the procedure. The day before colonoscopy, they were allowed to eat a regular breakfast and lunch but only clear liquids for dinner.

The patients in the whole-dose group received 4 L of GoLYTELY beginning at 5 p.m. the evening before the colonoscopy, and their diet was limited to clear liquids on the day before the procedure, Dr. Lim said.

The endoscopist, who was blinded to the patient's bowel preparation regimen, rated the quality of bowel cleansing via the Ottawa Bowel Preparation Quality Scale. The tool uses a 5-point scale for different regions of the colon, with lower scores being better.

Scores for the split-dose group, compared with the whole-dose group, were 0.63 vs. 1.7 for the right colon, 0.60 vs. 1.45 for the midcolon, and 2.35 vs. 4.54 for overall cleansing scores, said Dr. Lim of Rush University, Chicago. Scores also were lower (but not significantly so) in the split-dose group for the quality of cleansing in the rectosigmoid colon and for colonic fluid.

Before being sedated for the colonoscopy, patients completed a questionnaire about the bowel preparation. One patient (5%) in the split-dose group reported abdominal pain or cramping, compared with 10 patients (45%) in the whole-dose group, Dr. Lim said. The split-dose group also was less likely to report nausea, vomiting, bloating, anal irritation, headache, or sleep disturbance, but these differences did not reach statistical significance.

“We are encouraged by our initial findings, and as our sample size increases, we expect to further demonstrate that split-dose prep is statistically superior in symptoms, tolerance, and overall colon cleansing” for inpatients, she said.

Dr. Lim reported having no conflicts of interest related to the study.

My Take

Data Favor Split Dosing

Split dosing has been directly tested in 10 randomized trials, and all 10 showed it to be more effective than day-before dosing.

The American Society of Anesthesiology guidelines on fasting prior to procedures allow clear liquids until 2 hours prior to sedation. These guidelines have a strong evidence base, so split dosing is safe and effective and in several studies has been better tolerated than day-before dosing.

DOUGLAS K. REX, M.D., is distinguished professor of medicine at Indiana University, Indianapolis, and director of endoscopy at Indiana University Hospital. He is a consultant to Fleet Laboratories and has received research support from Braintree Scientific.

SAN DIEGO — Split-dose bowel preparation was found to be superior to a conventional whole-dose bowel cleansing regimen in a randomized, prospective study of 43 hospital inpatients.

The 22 patients who were randomized to a split-dose regimen of polyethylene glycol electrolyte solution (GoLYTELY) to purge the colon reported less abdominal pain or cramping, were more likely to be willing to undergo the procedure again, and achieved better colon cleansing, compared with 21 patients in the whole-dose group. These differences between groups were statistically significant, Dr. Roxanne Lim and her associates reported at the annual meeting of the American College of Gastroenterology.

In Dr. Lim's study, the indications for colonoscopy in these hospitalized patients included GI bleeding, abdominal pain, anemia, diarrhea, or an abnormal result on abdominal imaging.

The patients in the split-dose group received 2 L of GoLYTELY beginning at 5 p.m. the evening before the colonoscopy, and then another 2 L beginning at 5 a.m. the morning of the procedure. The day before colonoscopy, they were allowed to eat a regular breakfast and lunch but only clear liquids for dinner.

The patients in the whole-dose group received 4 L of GoLYTELY beginning at 5 p.m. the evening before the colonoscopy, and their diet was limited to clear liquids on the day before the procedure, Dr. Lim said.

The endoscopist, who was blinded to the patient's bowel preparation regimen, rated the quality of bowel cleansing via the Ottawa Bowel Preparation Quality Scale. The tool uses a 5-point scale for different regions of the colon, with lower scores being better.

Scores for the split-dose group, compared with the whole-dose group, were 0.63 vs. 1.7 for the right colon, 0.60 vs. 1.45 for the midcolon, and 2.35 vs. 4.54 for overall cleansing scores, said Dr. Lim of Rush University, Chicago. Scores also were lower (but not significantly so) in the split-dose group for the quality of cleansing in the rectosigmoid colon and for colonic fluid.

Before being sedated for the colonoscopy, patients completed a questionnaire about the bowel preparation. One patient (5%) in the split-dose group reported abdominal pain or cramping, compared with 10 patients (45%) in the whole-dose group, Dr. Lim said. The split-dose group also was less likely to report nausea, vomiting, bloating, anal irritation, headache, or sleep disturbance, but these differences did not reach statistical significance.

“We are encouraged by our initial findings, and as our sample size increases, we expect to further demonstrate that split-dose prep is statistically superior in symptoms, tolerance, and overall colon cleansing” for inpatients, she said.

Dr. Lim reported having no conflicts of interest related to the study.

My Take

Data Favor Split Dosing

Split dosing has been directly tested in 10 randomized trials, and all 10 showed it to be more effective than day-before dosing.

The American Society of Anesthesiology guidelines on fasting prior to procedures allow clear liquids until 2 hours prior to sedation. These guidelines have a strong evidence base, so split dosing is safe and effective and in several studies has been better tolerated than day-before dosing.

DOUGLAS K. REX, M.D., is distinguished professor of medicine at Indiana University, Indianapolis, and director of endoscopy at Indiana University Hospital. He is a consultant to Fleet Laboratories and has received research support from Braintree Scientific.

SAN DIEGO — Split-dose bowel preparation was found to be superior to a conventional whole-dose bowel cleansing regimen in a randomized, prospective study of 43 hospital inpatients.

The 22 patients who were randomized to a split-dose regimen of polyethylene glycol electrolyte solution (GoLYTELY) to purge the colon reported less abdominal pain or cramping, were more likely to be willing to undergo the procedure again, and achieved better colon cleansing, compared with 21 patients in the whole-dose group. These differences between groups were statistically significant, Dr. Roxanne Lim and her associates reported at the annual meeting of the American College of Gastroenterology.

In Dr. Lim's study, the indications for colonoscopy in these hospitalized patients included GI bleeding, abdominal pain, anemia, diarrhea, or an abnormal result on abdominal imaging.

The patients in the split-dose group received 2 L of GoLYTELY beginning at 5 p.m. the evening before the colonoscopy, and then another 2 L beginning at 5 a.m. the morning of the procedure. The day before colonoscopy, they were allowed to eat a regular breakfast and lunch but only clear liquids for dinner.

The patients in the whole-dose group received 4 L of GoLYTELY beginning at 5 p.m. the evening before the colonoscopy, and their diet was limited to clear liquids on the day before the procedure, Dr. Lim said.

The endoscopist, who was blinded to the patient's bowel preparation regimen, rated the quality of bowel cleansing via the Ottawa Bowel Preparation Quality Scale. The tool uses a 5-point scale for different regions of the colon, with lower scores being better.

Scores for the split-dose group, compared with the whole-dose group, were 0.63 vs. 1.7 for the right colon, 0.60 vs. 1.45 for the midcolon, and 2.35 vs. 4.54 for overall cleansing scores, said Dr. Lim of Rush University, Chicago. Scores also were lower (but not significantly so) in the split-dose group for the quality of cleansing in the rectosigmoid colon and for colonic fluid.

Before being sedated for the colonoscopy, patients completed a questionnaire about the bowel preparation. One patient (5%) in the split-dose group reported abdominal pain or cramping, compared with 10 patients (45%) in the whole-dose group, Dr. Lim said. The split-dose group also was less likely to report nausea, vomiting, bloating, anal irritation, headache, or sleep disturbance, but these differences did not reach statistical significance.

“We are encouraged by our initial findings, and as our sample size increases, we expect to further demonstrate that split-dose prep is statistically superior in symptoms, tolerance, and overall colon cleansing” for inpatients, she said.

Dr. Lim reported having no conflicts of interest related to the study.

My Take

Data Favor Split Dosing

Split dosing has been directly tested in 10 randomized trials, and all 10 showed it to be more effective than day-before dosing.

The American Society of Anesthesiology guidelines on fasting prior to procedures allow clear liquids until 2 hours prior to sedation. These guidelines have a strong evidence base, so split dosing is safe and effective and in several studies has been better tolerated than day-before dosing.

DOUGLAS K. REX, M.D., is distinguished professor of medicine at Indiana University, Indianapolis, and director of endoscopy at Indiana University Hospital. He is a consultant to Fleet Laboratories and has received research support from Braintree Scientific.