The risk that diabetes medications pose to cardiovascular health remains a contentious topic. Earlier this month, the FDA warned that saxagliptin and alogliptin, two dipeptidyl peptidase-4 (DPP-4) inhibitors used to treat type 2 diabetes, are associated with increased risk of heart failure. But then a new study in NEJM found that these drugs were not associated with increased risk of heart failure. While we await additional clarifying safety data, we'd recommend steering clear of DPP-4 inhibitors in most instances, particularly since their benefits on hard outcomes have not been well established.
In this JAMA Viewpoint, David Ludwig argues that the obesity epidemic may be responsible for recent increases in age-adjusted mortality. His recommendation: we need to address the root causes of obesity as a social, rather than as a personal, phenomenon.
Yet another well-conducted RCT confirms, as the editorialists explain, "Patients with subjective, vexing symptoms attributed to Lyme disease should not anticipate that even longer courses of antibiotics will produce relief."
We agree with this recent NEJM editorial that argues low-risk asymptomatic patients with carotid stenosis should be managed medically if not enrolled in ongoing clinical trials.
In this NEJM perspective, David Casarett argues that the "therapeutic illusion" leads many clinicians to be too confident in the potential benefits of their interventions. He offers an alternative: "If you see evidence of success, look for evidence of failure."
In addition to overestimating the benefits of what we do, we also often misinterpret trial results. The frequent misunderstanding and misuse of "P values" in clinical trials is an important concern, argues Demetrios Kyriacou in a recent JAMA opinion piece. We agree: both researchers and clinicians should place more emphasis on a Bayesian approach to interpreting trial results.
Over-confidence in our therapeutic interventions can also be countered by reading some of the important recent trials with negative results, such as these:
- Vitamin D supplementation led to no improvement in pain in patients with knee osteoarthritis and low vitamin D levels in this study recently published in JAMA.
- BEAT-HF was a well-conducted, but ultimately disappointing, trial of remote patient monitoring after hospitalization for heart failure. The negative results remind us that collecting extensive data on our patients (e.g., blood pressure, heart rate, symptoms, and weight) does not necessary lead to improved patient outcomes.
- Two key articles in a recent NEJM issue showed that a common surgical procedure for lumbar spinal stenosis -- combining decompression with fusion -- exposes patients to excessive surgical time and complications. For most patients, decompression alone is best.
Finally, some policy issues worth being aware of, as well as a video we strongly recommend:
- A disturbing glimpse into the underlying issues driving the 2014 Veterans Health Administration crisis triggered by a CNN investigative report.
- A New York Times investigative report finds that the NFL concussion study was deeply flawed.
- And finally ... here's a must-see, no frills, lecture by Vinay Prasad. There's no better argument for why keeping up with the literature from the Slow Medicine perspective is essential to the practice of medicine. Start exercising on a stationary bike or treadmill and press play!
"Updates in Slow Medicine" applies the latest medical research to support a thoughtful approach to clinical care. It is produced by Pieter Cohen, MD, of Harvard Medical School, and Michael Hochman, MD, of AltaMed Health System in Los Angeles. Rachael Bedard, MD, is a palliative care fellow at the Mount Sinai Hospital in New York. To learn more, visit their Facebook page.