BMJ  2005;331:1361 (10 December), doi:10.1136/bmj.331.7529.1361

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What's new in the other general journals

Conventional antipsychotic drugs are just as dangerous as newer agents

In April this year, the US Food and Drugs Administration (FDA) warned doctors that atypical antipsychotic drugs increased the risk of death among elderly people with dementia. Conventional antipsychotic drugs look just as dangerous, however, according to a recent study.

View larger version (44K): [in this window] [in a new window]   Credit: NEW ENGLAND JOURNAL OF MEDICINE

 

Detailed analysis of data from a prescription benefits programme for elderly people in Pennsylvania found 22 890 men and women aged 65 years or older who started taking an antipsychotic drug between 1994 and 2003. By 180 days after the start of treatment, 18% of those given a conventional drug were dead, compared with 15% of those given an atypical drug (relative risk 1.37, 95% CI 1.27 to 1.49).

The risk associated with older drugs such as chlorpromazine, thioridazine, and haloperidol was highest during the first 40 days of treatment (1.56, 1.37 to 1.78) and seemed independent of sex, age, and 20 other possible confounders.

Conventional antipsychotic drugs should be added to the FDA's warning about atypical drugs, say the authors. Doctors considering switching their prescribing habits should probably think again.

N Engl J Med 2005;353: 2335-41[Abstract/Full Text]

Antiretroviral drugs save lives, even in the poorest settings

International efforts are finally gearing up to provide desperately needed antiretroviral drugs to poor countries crippled by AIDS. A clinic in Haiti received its international funding in March 2003 and, over the next 14 months, recruited 1004 people with AIDS for antiretroviral treatment. Their results—described by an accompanying editorial (pp 2392-4) as remarkable—show just what can be achieved by a handful of dedicated staff even in a place like Port-au-Prince, "one of the most challenging urban centers in the world in which to implement a major public health intervention."

One year after the start of treatment, 87% of the adults and adolescents treated by the clinic (and 98% of the children) were still alive. Ninety two percent of the cohort were still taking their treatment—mostly triple therapy with generic drugs approved by the World Health Organization. Without treatment, about 70% of this cohort would have died within the year.

The clinic, which was based in an urban slum, achieved the same kind of treatment outcomes you might reasonably expect from a US clinic, even though more than half of the Haitian patients earned less than $1 a day, many were malnourished, and more than one in 10 had tuberculosis.

N Engl J Med 2005;353: 2325-34[Abstract/Full Text]

Nothing to choose between heparins in high risk patients with acute coronary syndrome

More than 10 years of research evaluating enoxaparin, a low molecular weight heparin, suggests that it works slightly better than traditional unfractionated heparin for people with an acute coronary syndrome, reducing the incidence of early death or heart attack by about 10%. It seems to work best, however for people with low or moderate risk of these events.

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In the latest large trial, of 9978 patients with high risk disease who needed aggressive medical treatment combined with early revascularisation, those taking enoxaparin did no better than those taking unfractionated heparin: 18% of both groups had either died or had a heart attack at the end of six months, and 7% were dead at the end of one year. Interpreting these findings is complicated by the fact that three quarters of the patients had had one or other antithrombin treatment before they were randomised.

These patients had a cocktail of other drugs too, in strict accordance with the latest guidelines. In this context, there seems little to choose between enoxaparin and unfractionated heparin, except that subcutaneous enoxaparin is more convenient.

JAMA 2005;294: 2594-600[Abstract/Full Text]

Sensible drinking won't protect your heart

Just in time for Christmas, researchers from New Zealand report that drinking is unlikely to be good for you, ever. The popular notion that one or two units of alcohol a day protects you from heart disease is well supported by observational data. But then, so was the equally popular notion that hormone replacement therapy protected women from heart disease—until proper clinical trials showed that observational data cannot always be trusted. It now seems likely that people who never drink are simply too different from people who drink sensibly to sort out the impact of alcohol on heart disease. In one recent study (Am J Prev Med 2005;28: 369-73[CrossRef][ISI][Medline]) 27 out of 30 cardiovascular risk factors were more common among abstainers than moderate drinkers. This makes moderate drinkers look good, even though their lower cardiovascular risk is nothing to do with the occasional glass of wine.

If anything, heavy drinking is more likely to be protective than light drinking, say the researchers. But there's little point in cleaning out your coronary arteries with a cellular poison that will simply kill you some other way.

Lancet 2005;366: 1911-2[CrossRef][ISI][Medline]

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