Comparative Benefits and Harms of Antidepressant, Psychological, Complementary, and Exercise Treatments for Major Depression

In a systematic review done by Gartlehner and colleagues, benefits and safety of second-generation antidepressants were compared with psychological, complementary and alternative medicine (CAM) and exercise treatments as first and second-step interventions in adults with acute major depressive disorder (MDD). They searched many data sources like MEDLINE and the Cochrane Library from 1990 to September 2015 for patients who were treated with second-generation antidepressants, psychological interventions, CAM interventions, exercise, or a combination of any of these treatments. Overall, they found that there was no significant differences in the efficacy of second-generation antidepressants and other types of treatments as first-step treatments. Also, second-generation antidepressants in general had higher risk of adverse events compared to the other interventions. The intervention with the strongest evidence was cognitive behavioral therapy (CBT).

I found the results of this systematic review to be very interesting because I would not have guessed that the effectiveness of CBT would be comparable to that of antidepressant medications. I feel that both interventions are very valid in treating acute MDD, and that choosing between the two will be choosing which risks are most manageable. Seeing how CBT can be effective, I wonder how other interventions, like exercise, will compare. These options may seem a lot more appealing to patients as they would not have to use a medication to treat their condition. I hope that in the future more studies will take a closer look at comparing the efficacy and safety of antidepressants and other non-medication based therapies.

Ann Intern Med. 2016;164:331-341.

Effects on Clinical Outcomes of Adding Dipeptidyl Peptidase-4 Inhibitors Versus Sulfonylureas to Metformin Therapy in Patients With Type 2 Diabetes Mellitus

In an observation study published in the Annals of Internal Medicine, a group of researchers compared the outcomes of adding a dipeptidyl peptidase-4 (DPP-4) inhibitor versus a sulfonylurea to metformin therapy. The study occurred in Taiwan and used the country’s National Health Insurance Research Database to study patients between 2009 and 2012. It included patients taking metformin who were later additionally prescribed either a DPP-4 inhibitor or sulfonylurea, but excluded patients who were also taking any other medications to manage their diabetes. Outcomes considered were mortality, MACEs (a measure of hospitalizations from stroke, myocardial infarction, and heart failure), and hospitalization for hypoglycemia. The study ended up examining 10,131 DPP-4 inhibitor users, 60,209 sulfonylurea users, and 10,890 propensity score-matched pairs.

Among the patients included in the study, 563 (5.6%) DPP-4 inhibitor users and 4425 (7.3%) sulfonylurea users died before the follow-up. Using the propensity score-matched pairs, it was observed that DPP-4 inhibitor users had lower risks of all-cause death, MACEs, and hypoglycemia. Risks for myocardial infarction and hospitalization for heart failure were not significantly different between the two groups.

The data gathered from this study can be very beneficial for choosing which medication is best for a patient. In patients at greater risk for cardiovascular events, it may be best to prescribe a DPP-4 inhibitor over a sulfonylurea if they are already taking metformin. I also wonder how this data might be translated into practice. Since all the data is from Taiwan, I had to wonder if there are any genetic differences between this group of people and others that could affect the outcomes of treatment. I’m curious to see future studies that compare the outcomes of DPP-4 inhibitors and sulfonylureas in other populations to see how it compares to this study’s findings.

Ann Intern Med. 2015;163:663-672.

Effects of Initiating Moderate Alcohol Intake on Cardiometabolic Risk in Adults With Type 2 Diabetes

In a study published in the Annals of Internal Medicine, a team looked into the health benefits of moderate alcohol intake, a topic commonly debated. They randomly assigned participants to either drink 150 mL of mineral water, white wine, or red wine at dinner in a 1:1:1 ratio. All the participants had T2DM and were drinking more than 1 alcoholic drink per week or using an insulin pump. They were also required to follow a “Mediterranean diet” as outlined in their article. Blood samples collected at 0, 6, and 24 months were analyzed for lipid levels, glycemic control, and other data. After two years, the HDL levels in the red wine group significantly increased by 0.09 mmol/L, compared to the 0.04 mmol/L of the mineral water group. Bodyweight and blood pressure reductions among all the groups were about the same after 2 years. In participants with available DNA samples, the effect of the gene ADH1B, which encodes for an alcohol dehydrogenase, was also looked at. In people carrying the wild-type allele, glycemic control and blood pressure improvements were greater compared to those carrying the other allele.

The results of this study supports the idea that moderate consumption of alcohol can be beneficial towards ones health. The study did not see any negative effects from the daily consumption, so it safe and may help reduce cardiometabolic risk. Reading this article helped dispel my previous notion that drinking wine wasn’t actually beneficial to health. I had thought that it was just a misconception and didn’t actually have any scientific evidence to back up the claims of its benefits. Seeing that this study only looked at white and red wine, I am curious to see possible future studies on the benefits of other types of alcohol, like beer, spirits, and other alcoholic beverages.

Ann Intern Med. 2015;163:569-579.

Acupuncture for Menopausal Hot Flashes

In many Eastern countries, there are people who approach health in a very different way than Western countries. One of the methods of healing they believe in is acupuncture. They think this procedure helps promote healing and the free flow of energy within the body. In an article published in the Annals of Internal Medicine, a team looked at the effectiveness acupuncture in relieving the symptoms associated with menopausal hot flashes. The study took place in Australia and included women who were postmenopausal or in the last menopausal transition. 327 women were randomly assigned to receive a standardized acupuncture session (163) or a sham acupuncture (164) 10 times over 8 weeks. The outcomes that they were looking for was a score based on the intensity of hot flashes experienced and how long they experienced them for, assessed at 4 weeks, end of treatment, and then 3 and 6 months after end of treatment.

The results of the study was that there was no significant advantage of the acupuncture over the sham acupuncture. Throughout the time period, 4 weeks into the treatment and 6 months after the end of treatment, the scores of both groups remained pretty much the same. The results of this study may point towards the ineffectiveness of these acupuncture sessions in treating the symptoms of menopausal hot flashes, but it may not be completely that way. Compared to no treatment, both the sham group and actual acupuncture group had improved symptoms. This could be from a sort of placebo effect. Acupuncture may not have had an actual effect on the symptoms, but the act of a treatment the patient believed in proved to have some positive effect.

Ann Intern Med. 2016;164:146-154.

Trial of Continuous or Interrupted Chest Compressions during CPR

In a study sponsored by the National Heart, Lung, and Blood Institute and many others, the effectiveness of continuous versus interrupted chest compressions during CPR was looked at. This research occurred at 114 EMS agencies and focused on adults with non-trauma-related out-of-hospital cardiac arrest. Agencies were randomly assigned to have its staff perform either continuous or interrupted chest compressions, and twice a year switched to the other resuscitation strategy. Continuous chest compressions were identified as the intervention group and would receive compressions at 100 compressions per minute with ventilations whenever possible at a rate of 10 ventilations per minute. Interrupted chest compressions (the control group) were defined as being at a rate of 100 compressions per minute, but having 2 ventilations after every 30 compressions. The kind of outcomes the study was looking for was whether the patient died or not, and if the patient experienced any neurologic damage.

23,711 patients were included for the final data analysis, with 12,653 in the intervention group and 11,058 in the control. 9% of the patients in the intervention group survived hospital discharge while 9.7% of patients in the control group did so. Among the patients with data on neurologic status, 7.7% of patients in the control group survived with favorable neurologic function compared the 7% of patients in the intervention group. Overall, there was not a significant difference in the survival rates or neurologic function between the strategies of continuous or interrupted chest compressions.

I found this study to be really interesting, because I sometimes hear about the proper way to provide CPR, whether or not rescue breaths are included in the process. According to the 2015 American Heart Association CPR guidelines, compressions should be given in all situations, and if a trained rescuer is able to, he or she should provide 2 rescue breaths for every 30 compressions. Their reasoning for this was that only compressions would be easy for the untrained, and that current research shows that there isn’t too much of a difference between the survival rates of compressions only versus compressions and rescue breath. This study supports the AHA’s claim and recommendations on how to perform CPR. I am really curious on what future studies may discover, especially in terms of what type of strategy will provide a significantly higher survival rate.

N Engl J Med. 2015;373:2203-14.

Trends in Prescription Drug Use Among Adults in the United States From 1999-2012

An article was recently published in JAMA looking at the prescription drug use and its trends over the past decade and more. The article used data from the National Health and Nutrition Examination Survey (NHANES). The data collected by this investigation includes age group, sex, ethnicity, and much more about the medications. Information on what drugs they were using in the past month were collected, allowing the research team to study the trends in prescription medication use over the span of many years. The prevalence of prescription drug use rose by about 8% from 51% in the first cycle in 1999-2000 to 59% in 2011-2012. The number of people taking over 5 prescription medications at once also increased by around 6.6%, from 8.2% to around 15%. The use of antihypertensives, antihyperlipidemics, and antidepressants also rose significantly, while the use other classes like prescription analgesics and sex hormones stayed stabled or decreased. The article also points out many other notable trends based on use in certain age groups, ethnicities, and trends in specific medications.

Looking at the trends of prescription drug use in the country can provide a lot of information about the health of the country and about the state of current medications. Increases in certain classes of drugs, like antihypertensives, can indicate that the occurrence of this condition is on the rise. This could be from the declining health of the nation or certain risk factors being more prominent now than in the past. Changes in trends could also be from more public acceptance of prescription medications, better drugs, or a combination of many factors. The data and trends looked at in this article is very interesting and could possibly be used to gain insight on future trends, predicting the impact of new policies, drugs, or other events mirroring past occurrences.

JAMA. 2015;314(17):1818-1830.

Effects of Nicotine Patch vs Varenicline vs Combination Nicotine Replacement Therapy on Smoking Cessation

Smoking tobacco is a widespread problem throughout the world, and there have been many attempts to create pharmacotherapies for smoking cessation. A study in the Journal of the American Medical Association compared traditional nicotine replacement therapy (NRT), varenicline, and a combination nicotine replacement therapy (C-NRT) in 1086 smokers. The difference in abstinence rates between the NRT patch and the other two therapies were not considered to be significant. It was also found that those in the C-NRT and varenicline groups had significantly lower withdrawal ratings than those just using the patch. The authors mention some problems the study could have faced, including low adherence to the therapies, length of the study, and also it being an open-label study where the patients knew what they were taking.

With how common smoking is, studies revolving around smoking cessation is important. While this study may have some flaws, it illustrates that all these three therapies have an effect on motivating smokers to quit smoking. If the non-prescription patch is as effective as the other two prescription therapies, it can greatly influence some smokers’ decisions about trying to quit smoking. The patch will be a lot cheaper and accessible, thus be able to reach a larger population. A big problem the study pointed out that is also common in other smoking cessation studies is the somewhat low adherence, rates being a little below 50%. In the smokers that did adhere, results could be seen from the lower amount of cigarettes they smoked or even completely quitting. Quitting smoking will greatly improve the health of a person, and these pharmacotherapies can help one with the process.

JAMA. 2016;315(4):371-379.

Less than half of U.S. kids under age two fully vaccinated against flu

Vaccination rates among children under the age of 2 years have been alarmingly low for the past decade, if not more. In the 2011-2012 flu season, only 45 percent of infants aged 7 to 23 months were vaccinated. While compared to the 5 percent rate in 2002-2003, this is step in the right direction, but more needs to be done to continue raising the vaccination rates among infants. In some states, the vaccination rate is as low as 24 percent, meaning that 3 in 4 babies are at risk to influenza. A contributing factor to these low vaccination rates is that for an infant’s first vaccination, they need two doses of the vaccine. Nearly 36 percent of children end up only receiving the first dose and end up not being fully vaccinated.

Pharmacists have already began seeing changes in immunization laws over the past couple years, especially in the restrictions on patient-age. At the beginning of 2015, only 27 states allowed pharmacists to vaccinate patients of any age, while there were 8 states where pharmacists could only vaccinate people older than the age of 18, Pennsylvania being one of them (until June 26th, where a bill was passed lowering the minimum age to 9). These changes can prove to be instrumental in raising vaccination rates across the country. Increasing the access to these immunization services can make a huge impact on the country’s health and encourage more people to stay current on their vaccinations. Hopefully in the near future, legislators will realize the potential of pharmacists immunizing and allow for them to do so all over the country, and not just in select states.

Pediatrics. 2016; 137(3): .