New, True & Poo. Faculty/Presenter Disclosure

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1 New, True & Poo Unpleasant Truths Comforting Lies Tina, Mike K, Adrienne, Mike A, Evidence & CPD Program, Alberta College of Family Physicians Department of Family Medicine, University of Alberta Faculty/Presenter Disclosure Faculty/Presenter: Mike Allan, Mike Kolber & Tina Korownyk Where we get Personal $: U of A, Alberta Health Faculty/Presenter: Adrienne Lindblad (ACFP salary) Where we get Grant/ Program $: Alberta College of Family Physicians, Other Colleges of Family Physicians, Toward Optimized Practice, Other non profit organizer Relationships with commercial interests: Grants/Research Support: Not applicable Speakers Bureau/Honoraria: Not applicable Consulting Fees: Not applicable Other: None 1

2 What s New What s True What s Poo TK Reducing Peanuts & other Allergies RCT 640 infants (mean 8 months) at high risk randomized to peanuts (~3x/wk) or avoid to age 5 Outcome: compliance quite good. No baseline allergy: allergy in 2% consume vs 14% avoid Baseline mild allergy: allergy in 11% consume vs 35% avoid Another RCTs of 6 allergenic foods: poor compliance (~32%) minimized diff. Analysis of compliers was positive. 2 Bottom line: Avoiding peanuts early increases risk of developing peanut allergies (and year avoidance at age 5 does not change this). N Engl J Med 2015;372: ) NEJM 2016;374:

3 BP Thresholds & Targets Overall in DMs Sys Rev: 49 BP RCTs, 73,738 diabetes pts Baseline BP Attained BP Others similar except stroke (continue to improve) Meta regression shows benefit crosses to harm at 141mmHg (baseline) and 132 mmhg (attained). Bottom line: Treating Systolic BP <140 and/or targeting <130 in type II diabetes likely unadvisable. Brunstrom BMJ 2016;352:i717 MK Sleep Apnea, CPAP & CVD RCT: 2717 pts (age 61, 81% male, 100% CVD), mean 28 desats (of 4%) /hr. CPAP vs no CPAP x 3.7 yrs. Outcome: mean CPAP use 3.3 h/night (42% >4h) CVD: 17% vs 15.4% Death & CVD death: No diff Stat sign: Epworth 2.5 (out of 24) better, QoL 1 2% better, Not sign: MVA 3% vs 3.5%, injurious accidents 7.4% vs 8.8% (p=0.06), Bottom Line: CPAP nothing for hard outcomes, works for sleepiness and other changes are slight (1 2%) or nothing. McEvoy NEJM DOI: /NEJMoa

4 AL HOPE 3: Statin in Moderate CVD Risk HOPE 3 RCT (12,705 pts) intermediate risk (calculated risk ~12% 10 yr risk) Rosuvastatin 10mg vs placebo Outcomes: After 5.6 years (LDLD down 27%) CVD death/mi/stroke: HR 0.76 ( ): 3.7% vs 4.8% (NNT 91) No statistical diff in death or new Diabetes. Harms: Muscle Pain or weakness 5.8% vs 4.7%, NNH 91 Bottom Line: In an intermediate risk group, rosuvastatin 10mg did exactly what you would expect it to do (ie reduce risk by about 25%). Yusuf S, HOPE 3, NEJM 2016: DOI: /NEJMoa TK Essential Tremor: A Real Solution? RCT: 76 patients, age 71, 68% male focused ultrasound thalamotomy vs sham Mean hand tremor ~18 (out of 32) Outcome (at 3 months): (in contralateral hand) No change with sham treatment Mean 47% improvement at 3 months, 40% at 12 months CRST (total tremor): improved 40% from baseline Quality of life, etc: all ++ better Harms: 38% paresthesia/numbness, 36% gait disturbance By 12 months: 14% and 9% respectively. Bottom Line: Promising for serious hand tremor. N Engl J Med 2016;375:

5 TFP update In asthma, are LABAs (with steroid) safe. TFP #16 Long acting beta agonist safety. 3 RCTs: formoterol/budesonide (11,693); salmeterol/fluticasone (11,679 adults & 6,208 age 4 11) x26 weeks. All vs steroid alone. Outcome: Serious Asthma AE %, no diff E.g. kids: 27 (0.9%) vs 21 (0.7%), HR 1.28 ( ), Rest smaller numeric differences (nothing remotely stat sign) Exacerbations reduced 1.5 2% by combo (vs steroid) Bottom line: LABA safe added steroid but little benefit over steroid alone. N Engl J Med 2016;375: N Engl J Med 2016;374: N Engl J Med 2016;375:

6 MK Cyclobenzaprine for back pain TFP: #143 July 2015: NNT 3 9 in first wk RCT: all 10 d Naprosyn (500 BID): cyclobenzaprine 5mg, oxycodone/acetaminophen 5/325mg, placebo (1 2 TID) Frequent/always back pain at d6: 29%, 28%, 35% Return to normal activities: 4d, 4d and 5d. Note: 22% never took >1 pill Bottom Line: Most patients taking high dose naprosyn don t need more. Most people are better/mostly better in 1 week. JAMA. 2015;314(15): The Pharmaceutical Graveyard 6

7 AL Semaglutide (GLP 1) and CVD RCT 3297 pts, x2.1 yrs, Semaglutide 0.5 or 1mg q 1 wk. Mean age 65 61% male, A1c 8.7%, DM x14 yrs, past CVD Outcome: A1c 7.6% 0.5mg, 7.3% 1mg, 8.3% placebo, CVD: 6.6% semaglutide vs 8.9% placebo, HR 0.74 ( ), No diff in mortality Diabetic retinopathy 3% vs 1.8% (worse), nephropathy 3.8% vs 6.1%, wgt loss was kg over placebo, d/ due to AE 13% vs 7% (p<0.001), GI AE 52% vs 35% (p<0.001) Bottom Line: Improved CVD but more AE including worse retinopathy. Marso SP. NEJM DOI: /NEJMoa TK Liraglutide (GLP-1) and CVD RCT liraglutide 1.8mg vs placebo, 9340 pts, x3.8 yrs 64% male, age 64, DM 13 yrs, A1c 8.7%, CVD 82%. Outcome (A1c ~1% diff, but 0.4% at end; ~7.7% vs 8.1%) CVD: HR 0.87 ( ), 14.9% vs 13%, NNT=53. Death: 9.6% vs 8.2% (NNT 72) Microvascular: NNT 67 (via nephropathy), retinopathy +0.3% Note: weight 2.3 kg better, severe Hypo 0.9% less(!) Total neoplasm (10.1% vs 9% ns), pancreatic Ca (0.3 vs 0.1%, p=0.06), gall bladder disease (NNH 82); N/V/D (NNH each) Bottom-Line: Works! NNT ~50 in high risk diabetics. Not target based. (note: lixisenatide RCT found no effect) 1. Marso SP. NEJM 2016 DOI: /NEJMoa NEJM 2015;373:

8 RESEARCH MK You get what you pay for? 82 people, electric shock pain RCT. All Placebo Group 1: pain pill worth $2.50 (similar to codeine) but faster etc. Group 2: Pain pill worth $0.10, discounted medicine. Outcome: High cost = better mean pain ~12mm 85% high cost got better vs 61% of discounted Bottom Line: If it s expensive, it s better. (May explain some of patient complaints around generics). JAMA Mar 5;299(9):

9 AL Honesty & Cultural Expectations 293 (55% female) college students, mean age 19. ½ to lie detector & ½ to anxiety machine (neither functioning) Results: Not many changed on lie detector. But some small changes around sex,.. Bottom Line: We re not honest about sex, in culturally acceptable directions. Number of Past Sexual Partners No Lie Detector Lie Detector Sex Roles (2013) 68: Kissing Makes it all Better! Study 1: 30 allergic rhinitis & 30 atopic dermatitis Age 29, 53% female, Japanese, do not kiss habitually kissed with lover or spouse freely for 30 min alone in a room with closed doors while listening to soft music The Beauty and the Beast, When You Wish Upon a Star, My Heart Will Go On, Love is a Many Splendored Thing, Moon River, Sunrise Sunset, Can You Feel the Love Tonight. Skin Prick Test Outcomes: 20 30% reduction in neurotrophins Wheals: 8mm before & 5.4 after kissing (no diff if hugging) Bottom Line: Kissing treats atopy. Dose and potency still unresolved. Physiology & Behavior 80 (2003)

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