Annals
Established in 1927 by the American College of Physicians

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3 May 2011 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at acollom@acponline.org

1. For Older COPD Patients, Long-acting Inhaled Beta-agonists Increase Survival Over Anticholinergics

Long-acting medications such as inhaled beta-agonists and anticholinergic agents are commonly prescribed to manage chronic obstructive pulmonary disease (COPD). Both drugs have been shown to decrease exacerbations and hospitalizations and improve COPD symptoms, lung function, quality of life, and possibly mortality. However, it is not known which therapy is a better choice for initial therapy. Researchers studied patients aged 66 years or older who were diagnosed with COPD and were newly prescribed either an inhaled, long-acting beta-agonist or an anticholinergic between 2003 and 2007. The patients were followed for up to 5.5 years to compare survival rates between the two treatment groups. The researchers found that older adults initially prescribed long-acting inhaled beta-agonists had lower mortality than those initially prescribed long-acting anticholinergics. The researchers recommend further study regarding the relative benefits of long-acting anticholinergics.

2. Omalizumab Improves Symptoms for Patients with Uncontrolled Severe Allergic Asthma

Patients with uncontrolled allergic asthma are often prescribed a combination of inhaled corticosteroids (ICS) and long-acting beta-agonists (LABAs). Even with both medications, these patients can have flare ups that require use of a “rescue inhaler” or require treatment with oral or intravenous steroids. Omalizumab is a medication that blocks the ability of a blood protein to increase airway inflammation and constriction. Researchers studied 850 patients aged 12 to 75 years with severe, uncontrolled asthma resulting in nighttime awakenings, frequent daytime rescue inhaler use, and at least one acute exacerbation of asthma in the past year requiring the use of steroids. Patients were randomly assigned to receive either placebo or an injection of omalizumab every two to four weeks for 48 weeks in addition to ongoing treatment with ICS and LABAs. Patients that received omalizumab in addition to ongoing ICS and LABAS had fewer asthma exacerbations, reduced rescue inhaler use, and improved symptom and quality-of-life scores over 48 weeks.

3. Patient-tailored Guidelines Can Save Money, Improve Outcomes, But May be Out of Reach

Clinical guidelines make it simple and efficient for physicians to make evidence-based treatment decisions for their patients. A common criticism of guidelines is that they narrowly focus on specific risk factors to determine who should and should not receive treatment. Researchers sought to determine if individualized guidelines based on patient characteristics (age, sex, blood pressure, cholesterol, family history, etc.) could achieve better outcomes and save costs compared to current guidelines. Researchers used the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines as a basis for comparison. According to the JNC 7 guidelines, patients should receive hypertensive treatment if their blood pressure exceeds 140/90 or 130 /80 if they have diabetes or chronic kidney disease. Using a computer model, patients were treated using either JNC 7 guidelines, individualized guidelines (treatment in decreasing order of expected benefit), or random care (treatment of persons selected at random). The researchers found that compared to random care, individualized guidelines could prevent the same number of myocardial infarctions (MIs) and strokes as JNC 7 guidelines at a cost that is 67% lower than using JNC 7 guidelines, or could prevent 43% more MIs and strokes for the same cost as treatment according to the JNC 7 guidelines. According to the author of an accompanying editorial, tailoring recommendations is not as easy as it sounds. Guidelines tailored for individuals will be more complex and more difficult to implement in practice. Experts are faced with a challenging opportunity to figure out how to create guidelines that are tailored for individual patients but are still easy to implement.

4. AHRQ Technical Brief: No Evidence to Support Clinical Use of Stereotactic Body Radiation Therapy Over Other Radiation Therapies

Stereotactic body radiation therapy (SBRT) is a treatment technique that uses special equipment to position a patient and precisely deliver external radiation therapy to tumors in the body. SBRT is typically delivered in one to five treatments, with a very high radiation dose of 20 to 60 Gy. This type of radiation therapy can be preferred by patients because of the convenience of fewer sessions. Researchers reviewed 124 relevant published studies to develop a technical brief on the current state of SBRT for solid malignant tumors. They found several limitations in the available literature that raise concerns about the widespread use of SBRT. According to the authors, there is limited research comparing the safety and efficacy of SBRT to other forms of external-beam radiation therapy. In addition, the technique is used on various cancer types, but most of the published studies were for tumors located in the lung or thorax. There were fewer than 10 studies each for tumors of the pancreas, liver, colon, uterus, pelvis, sacrum, kidney, and prostate. While there were many studies for cancer, comparative studies are needed to provide convincing evidence that SBRT will have advantages over other radiation therapies in the clinical setting.