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In episode 188, James and Mike go all PREMIUM for the holidays and discuss a few studies that have the potential to change practice. These include info on the impact or lack thereof of fasting on cholesterol measurements, the impact of A1c on functional decline and a head-to-head comparison of metformin and glipizide.

1) Variability in cholesterol measurement

JAMA 1992;267:1652-60

2) Effect of fasting on cholesterol measurements

Arch Intern Med 2012;172:1707-10

3) Impact of glycosylated hemoglobin on functional decline

J Am Geriatr Soc 2012;60:1215–21

4) SPREAD-DIMCAD

Diabetes Care 2012 Dec 10 (Epub ahead of print)

In episode 187, Mike and James – actually it was mainly Mike – finally get to the painful end of the neuropathic pain trilogy. We discuss all the second and third line options and conclude that there are a lot of options but none work really well and side effects are often limiting. At the end we recommend that clinicians get patients with neuropathic pain to listen to the TEC podcast as this gives the equivalent effect to that seen with high dose narcotics.

Show notes

1) Carbamazepine

Cochrane CD005451

2) Valproate

Cochrane CD009183

3) Opiods

Cochrane CD006146

4) Capsaicin

Cochrane CD007393

Cochrane CD010111

Clin J Pain 2012;28:101–7

Neurology 2008;70;2305-13

5) Topical lidocaine

Cochrane CD004846

6) Lacosamide

Cochrane CD009318

7) Lamotrigine

Cochrane CD006044

8) Cannabis

Pain Medicine 2009;10:1353-68

CADTH: 13 July 2010, Cannabinoids for the Management of Neuropathic Pain

9) Therapeutic touch

Cochrane CD006535

10) Systemic local anesthetics

Cochrane CD003345

11) TENS machines

Cochrane CD003222

12) Psychology (mainly CBT)

Cochrane CD007407

13) Antipsychotics

Cochrane CD004844

14) Vitamin B

Cochrane CD004573

15) Other

Cochrane CD003904

Cochrane CD007796

16) Drug combinations

Cochrane CD008943

In episode 186, Mike and James continue on the path of the treatment of neuropathic pain and we explore the whole murky world of gabapentin and pregabalin. We come to the conclusion that while these drugs produce an effect and also produce side effects it’s all about the overall magnitude of that effect. Go figure.

Show notes

1) Gabapentin

Cochrane review

CD007938

N Engl J Med 2009;361:1963-71 

Therapeutics Letter #75 – 2009 

2) Pregabalin

Cochrane review

CD007076

CDR Sept 23, 2009, pregabalin review 

In episode 185, Mike does a stellar job of reviewing the painfully complex literature around the treatment of neuropathic pain – diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia. James as usual just adds to the painful nature of the whole process. In this particular episode we discuss the use of antidepressants and at the end we realize we shouldn’t call these agents antidepressants and decide to call them Kevin.

Show notes

1) Antidepressants for neuropathic pain

Cochrane CD005454

2) Duloxetine for neuropathic pain

Cochrane CD007115

In episode 184, James and Mike don their PREMIUM critical appraisal hats yet again to report the results of important recent studies that examine the impact two “new” drugs, aliskiren and dalcetrapib, have on clinically important outcomes. Unfortunately, these well-designed studies show yet again there is no guarantee that if you change cholesterol or blood pressure that clinically important outcomes will decrease.

Show notes

1) Aliskiren

N Engl J Med 2012.
DOI: 10.1056/NEJMoa1208799 

2) Dalcetrapib

N Engl J Med 2012.
DOI: 10.1056/NEJMoa1206797

In episode 183, the Mikes and James shine a bright light on the evidence around the use of proton pump inhibitors. We look at the good and bad outcomes and realize it is all about the numbers and the quality of the evidence. After 45 minutes the bright light and our knowledge starts to dim until we get to the end of the podcast when we shut the light off completely.

Show notes

1) Benefit of PPIs versus H2RA and placebo

Acute 

Cochrane Library CD003244

Chronic http://www.cks.nhs.uk/dyspepsia_proven_gord/evidence/supporting_evidence/no_response_to_initial_therapy/extending_treatment_duration#-330424

2) Prevention of NSAID –induced endoscopic ulcers

Cochrane Library CD002296

3) Stress ulcers

Crit Care Med 2010;38:1-7

4) Rebound

Gastroenterology 2009;137:80-7

5) Withdrawal

Gastroenterology 2001;121:1095–1100

Aliment Pharmacol Ther 2007;25:709–714

6) On demand use

Am J Gastroenterol 2007;102:642–653

7) Esomeprazole

Clin Gastro Hepat 2006;4:1452–8

8) Interactions

BMJ 2012;345:e4388 doi: 10.1136/bmj.e4388

9) Fractures

Drugs 2012;72:437-45

10) Pneumonia

Cleveland Clinic J Med 2011;78:39-49

11) C. difficile

Dig Dis Sci 2011;56:931–50

12) Iron and B12, and cancer

Dig Dis Sci 2011;56:931–50

In episode 182, the Mikes and James talk about the evidence behind the zoster vaccine. We give all the numbers you could possibly want to discuss this with your patients so that they can help you make up your mind what is best for them. As always, the greater the risk the greater the potential benefit. At the end of the podcast the Mikes wrap James in barbwire in an attempt to demonstrate to the listening audience the concept of post-herpetic neuralgia.

Show notes

1. Zoster vaccine evidence

N Engl J Med 2005;352:2271-84

Clinical Infectious Diseases 2012 (in press)

Clinical Infectious Diseases 2012;54:922–8

Ann Intern Med 2010;152:545-54

2. Zoster incidence etc

Can J Infect Dis Med Microbiol 2010;21:45-52 

CMAJ 2010. DOI:10.1503/cmaj.091711

BMJ 2000;321:1–4

Journal of Infectious Diseases 2012;206:190–6

Mayo Clin Proc 2011;86:88-93

National Advisory Committee on Immunization (NACI) 2010; 36: 1-19. Accessed October 15, 2012. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/10vol36/acs-1/index-eng.php

MMWR 2008; 57(5):1-30. Accessed October 15, 2012. http://www.cdc.gov/MMWR/preview/mmwrhtml/rr5705a1.htm 

In episode 181, James and the two Mikes (Alan and Kolber) discuss two new drugs – one for constipation (prucolapride) and one for gout (feboxustat). We conclude that despite the fact there are studies for both of these drugs published in the New England Journal of Medicine, they really are not ready for primetime.
Show notes
1) Prucolapride

In episode 180, Mike and James invite Mike Kolber back to go over the three major trials that have compared warfarin to the new oral anticoagulants. We try, with limited success, to put all the science into perspective. At the end of the podcast, against all odds, we each have a stroke and a major bleed at the same time which dampens our recommendations.

Show notes

1) Tools for Practice

Novel Oral Anti-coagulants (NOACs): is newer better? 

2) peterloewen.com for stroke risk and benefit calculator 

In episode 179, we again ask Tina Korownyk to join us to help with the topic of screening for lung cancer. We review the most recent study that looked at the risks and benefits of screening high-risk individuals (smoking history of at least 30 pack-years) with low dose CT. At the end we come up with the shocking conclusion that we need to discuss the benefits and risks with patients and that smoking cessation should be a priority.

Show notes

1) RCTs of low dose CT for lung cancer screening

NEJM 2011;365:395-409

ACP Journal Club. 2011;155:JC5-6

Am J Respir Crit Care Med 2009;180:445-453

2) Other useful info

Thorax 2012;67:296-301

Cochrane Database Syst Rev 2004:CD001991

Radiology 2005;235:259-65

Annals of Internal Medicine 2011;155:137-44

JAMA 2012;307:2418-2429

International Journal of Cancer 2007;120:868-74

http://www.lung.org/lung-disease/lung-cancer/lung-cancer-screening-guidelines/lung-cancer-screening.pdf

J Thorac Cardiovasc Surg 2012;144:33-8

JAMA 2005;294:1505-1510