Is Three Better Than Two?

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Is Three Better Than Two?

No, when it comes to installments of the Godfather trilogy. Likely yes, when it comes to inhaler therapy for moderate-to-severe persistent asthma.

Researchers conducted a systematic review and meta-analysis of 20 randomized clinical trials (N=11,894) to determine the efficacy of triple vs dual inhaler therapy in patients with moderate-to-severe persistent asthma. Specifically, is adding a long-acting muscarinic antagonist (LAMA) to inhaled corticosteroids (ICSs) and long-acting β2-agonists (LABAs) a good idea?

Apparently, it is! Triple therapy with a LAMA, ICS, and LABA was associated with a 17% relative risk reduction in severe asthma exacerbations in comparison with dual therapy with an ICS and LABA (with a number needed to treat [NNT] of around 20). No significant difference in adverse events existed between the groups. Triple therapy also conferred slightly better asthma control.

Surely the relative benefit must also lead to improved quality of life, right? Well, we hate to ruin a good story with actual data, but this reduction in severe exacerbations had no effect on a patient’s quality of life. Head-scratching. We can file this one away under “things that don’t make sense,” like why Jack didn’t even try to mount the Titanic door raft next to Rose. Things that make you go hmmm.

And one more thing: could this study potentially lead to improved inhaler coverage for patients? Here’s hoping!

Take Heart in This Dietary Study

Most of us are familiar with the benefits of the DASH (Dietary Approaches to Stop Hypertension) diet on cardiac biomarkers for cardiac injury, strain, and inflammation. What we haven’t known is how efforts to reduce sodium—alone or in combination with the DASH diet—affect these cardiac biomarkers.

In a controlled feeding study, 412 adults with a mean age of 48 years and a mean baseline blood pressure of 135/86 mm Hg were randomly assigned to the DASH diet or a control diet. Every four weeks participants in both groups were further stratified into one of three levels of sodium consumption: low (50 mmol/day), medium (100 mmol/day), and high (150 mmol/day). Body weight was kept consistent. Researchers measured cardiac injury, strain, and inflammation at baseline and after each feeding period. Here’s a table showing what they found:

The conclusion of this study is that the DASH diet plus sodium reduction was beneficial in reducing cardiac injury and strain, but DASH alone lowered cardiac inflammation.

So, what does this all mean? First, this study did not measure a reduction in clinically meaningful outcomes such as myocardial infarction or congestive heart failure. Next, it’s important to keep in mind the potential adverse effects related to a dramatic sodium reduction. Therefore, we must take these data with a grain of salt. Pun intended!

Shining a Light on Metastatic Prostate Cancer Cells

Imagine going from playing manhunt in the dark with camouflaged teens to hide-n-seek with a toddler under a blanket. Well, in the world of metastatic prostate cancer, the “game” just got a lot easier.

The FDA recently approved a tracer agent designed to help locate advanced prostate cancer. This tracer is the first of its kind commercially available in the United States for advanced prostate cancer. Its ability to expose previously hidden cancer cells is a game changer.

Locating these metastatic cancer cells at an earlier stage opens the door to the use of more targeted radiation, but will this actually improve outcomes? Only time will tell. In the meantime, we’re optimistic that this new agent will redefine how we view metastatic prostate cancer—literally and figuratively.

“But the Risk of Blood Clots Is Much Higher With Birth Control Pills”

How many times have you heard the above argument in response to the blood clot risk posed by the Johnson & Johnson COVID-19 vaccine? According to an article in The New York Times, this rhetoric not only failed to allay fears, but it also stoked some flames.

Many on social media and elsewhere were incensed that the risks of most contraceptive options were simply accepted. Where is the urgency to develop additional safer alternatives, they asked?

The online pushback was swift: women know the risks of birth control, and the benefits far outweigh the risks, so women should stop complaining. Naturally, many women found this dismissive, and the fury continued.

“They should be angry—women’s health just does not get equal attention,” said Dr. Eve Feinberg, a reproductive endocrinologist and infertility specialist at Northwestern University. “There’s a huge sex bias in all of medicine.”

It’s true that the benefits of contraceptive options far outweigh the harms, but it’s important for clinicians to initiate a conversation with patients about these risks, a conversation many women claim they’ve never had with their provider.

The Mickey Mantle of Migraine Medication

Like the Mick, rimegepant (Nurtec ODT) is now officially a switch-hitter.

The FDA recently expanded the drug’s indication to include the prevention of migraine in those with fewer than 15 headache days in a month, or episodic migraines. The drug had already been approved last year for the acute treatment of migraine in adults, with or without aura, regardless of the amount of migraine days per month.

“To have one medication patients can use to treat and prevent migraine will likely change the treatment paradigm for many of the millions of people who live with migraine,” said Peter Goadsby, co-author of the phase 3 preventive study of rimegepant.

In a randomized study of 747 patients, rimegepant, compared with placebo, decreased monthly migraine days by 4.3 days per month after three months of treatment.

Impressive! Maybe rimegepant is not in Mickey Mantle territory yet, but it could give Chipper Jones a run for his money.

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Healthcare Humor

An older man walks into his PCP’s office and says, “Please help me. I have a terrible problem with farting. It’s not really a social problem, because you can’t smell it or hear it, but I must have farted 20 times since talking to you.”

The clinician examines him, gives him a prescription for some pills, and tells him to come back in two weeks. After two weeks, the man comes back angry and says, “What was in those pills? I fart just as much! You still can’t hear them, but now they smell horrible!”

The clinician nods his head and says, “Great, that takes care of your sinus problem; now let’s work on your hearing.”

Finding the Intersection of Safety and Fun

Jack Nicholson, dust off your Staples Center chair. Comic Con cosplayers, twist up those Princess Leia buns. Parrot heads, prepare your margaritas!

The world is slowly reopening again, and that includes mass indoor gatherings. But before you confidently give patients the green light to safely attend these events, let’s go over some data on indoor COVID-19 transmission. An experiment conducted at an indoor concert in Spain on December 12, 2020 offers some key findings. (We know that date was five months ago, but the peer-reviewed article was published this past week.)

Researchers randomly assigned 465 people to attend a five-hour long indoor concert and sent a control group of 495 people back home. At the concert, safety measures included mandatory mask wearing, adequate air circulation, and prior rapid antigen testing for COVID-19. Eight days later, no cases of COVID-19 were seen in those who attended the concert, whereas two people in the control group tested positive. Remarkable! And what makes these results more remarkable is that at the time of the concert, no one had yet been vaccinated.

More research is needed, but we find this encouraging. Whether your jam is a concert or a sporting event, safe indoor fun—with the right precautions—is returning to a venue near you.

What a Difference Four Decades Make

If you’re old enough to have cranked up “Bette Davis Eyes” or “Jesse’s Girl” on your shiny new Walkman, you were around for the early ’80s. That means you may also remember the early days of the AIDS epidemic and can attest to the fear and uncertainty that plagued that difficult time in our history.

Believe it or not, today marks four decades since the initial five reports of AIDS—unnamed at that time—were published in the CDC’s Morbidity and Mortality Weekly Report (MMWR). We’ve come a long way from those terrifying early days of HIV/AIDS, thanks to clinical research and education. But more work is needed.

To continue efforts toward equitable access to services for those with HIV, the CDC and partners have assembled educational resources focused on continuing the dialogue on HIV/AIDS. You can also check out the CDC’s personal stories from the early days of the epidemic and explore their 40-year timeline of HIV/AIDS progress.

This day is also HIV Long-Term Survivors Awareness Day, acknowledging the 38 million people currently living with HIV and the significant burden this disease places on them and their support systems. We also want to remember the more than 32 million people worldwide who have lost their lives to this disease.

Interested in more healthcare news? Here are some other articles we don’t want you to miss:

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Not your typical medical newsletter… We get it, you see a lot of medical newsletters, so hear us out. This newsletter is intended to be fun, refreshing, and informative!

Every other week, we’ll highlight important medical news, sprinkled with some witty commentary, fun facts, giveaways, and more… because learning should be fun! Subscribe to receive the Morning Report directly.