In episode 145, Mike and James bring you, live on-tape from down-under, our presentation at the 2011 Conference for General Practice in New Zealand. We talk about why most new things aren’t much if any better and then discuss the issue of things like surrogate markers, physiological mechanisms, meta-analyses, selective publication/reporting, measurement/scales and “Risky” superlatives.
In episode 144, Mike and James finish up their discussion about headache prevention with a poignant yet stirring discussion of the use of antihypertensive and antiepileptic agents for migraine prevention. We show these drugs work and decide that they work not as antihypertensives or antiepileptics but have something to do with their ability to induce fairies to sprinkle magical dust on the brain. At the end we realise that even when it comes to fairy dust, low dose is the way to go.
Show notes
1) Propranolol for migraines
2) Lisinopril for migraine
3) Candesartan for migraine
4) Verapamil for headache
5) Hypertension treatment and headaches
6) Overview of pharmacological management
In episode 143, Mike and James quickly create headaches among their listeners but fortunately just as quickly get to a discussion about the prevention of headaches with antidepressants. We find out that tricyclics work but SSRIs don’t. To prove that point we both take high doses of fluoxetine during the podcast with no effect, except the clear effect it has on the quality of the podcast.
Show notes
Tricyclics for preventing headaches
BMJ 2010;341:c5222doi:10.1136/bmj.c5222.2
SSRIs for preventing headaches
Prophylaxis of migraine review
In episode 142, Mike and James finish off the elderly, but hopefully not literally, by discussing some key RCTs that help inform us as to a few medications that likely should be part of your discussion/armamentarium with your elderly patients. At the end Mike extols the virtues of low doses and James tells him I told you so.
Show notes
1) “Optimal” managaement of elderly patients with vascular disease
Am Heart J 2006;152:585-92
2) Drug withdrawal in the elderly
IMAJ 2007;9:430–434.
3) Withdrawing antipsychotics
JAMA 2005;294:1934-43
NEJM 2005:353:2335-41
Lancet Neurol 2009;8:151–57
PLoS Med 5(4): e76.doi:10.1371/journal.pmed.0050076
4) Testosterone
NEJM 2010; 363:109-22
5) BP in the elderly
Lancet 2000;355:865–872
Cochrane CD000028
N Engl J Med 2008;358:1887-98
Cardiol J 2009;16:379–385
Hypertens Res 2008;31:1595-601
Hypertension 2010;56:196-202
Circulation 2001;104:1923-6
6) Anticoagulation in the elderly
Lancet 2007;370:493–503
7) Rate control in the elderly with A fib
N Engl J Med 2010;362:1363-73
8) Low-dose iron
Am J Med 2005;118:1142-7
In episode 141, Mike and James whine about the Beers criteria that is used to evaluate drug use but in the end they realise that all drug use criteria are quite arbitrary and that individual drug use issues need to be dealt with individually. To that end we discuss general concepts as to how to review patients on polypharmacy.
Shownotes
1) Different drug use in the elderly criteria
Arch Intern Med 2003;163:2716-24
Pharmacother 2010;44:1968-75
Arch Intern Med 2007;167:781-7
Dtsch Arztebl Int 2010;107:543–51
2) Association of drug use criteria and bad outcomes
Ann Pharmacother 2007;41:438-8
Am J Med 2009;122,1142-9
J Am Geriatr Soc 2011;59:875-80
Ann Pharmacother 2010;44:1725-32
Age & Ageing 2008;37:673–9
Arch Intern Med 2011;171:1013-9
3) Studies of unsafe prescribing
Arch Intern Med 2009;169:1952-60
Drugs Aging 2008;25:61-70
J Gerontol A Biol Sci Med Sci 2007;62:1172-81
Arch Intern Med 2009;169:1952-1960
Drug Safety 2007;30:171-184
Drug Safety 2009;32:489-98
In episode 140, Mike and James do a lot of drugs in an attempt to bring a reality to the whole concept of polyharmacy. After recovering, we try to present a lucid and comprehensive approach to the issues of polypharmacy and come to the realisation that drugs can be good, bad and ugly all in the same person and you have to individualise to rationalise.
Show notes
1) Polypharmacy/polyproblem numbers
J Am Med Dir Assoc 2011 Aug 11
BMC Clinical Pharmacology 2010;10:16
Am J Geriatr Pharmacother 2007;5:345-51
2) Solutions?
In episode 139, James and Mike and Tina Korowynk talk about the available evidence for therapies for irritable bowel syndrome and our good friend and colleague Mike Kolber drops in for a few minutes at the end “runs through” the reality of the situation. We then talk about the recent publication of the largest trial of Cold-FX and find that what wasn’t shown to be statistically different is at least if not more important than what was shown to be statistically different.
Show notes
1) IBS evidence
2) The latest Cold-FX trial
Influenza Research and Treatment Volume 2011, Article ID 759051
In episode 138, MIke and James celebrate their triumphant return from New Zealand by inviting Tina Korownyk to help explain the risks associated with CT scans and other forms of radiation. In addition, we ask her to help Mike with his fear of airport scanners and find out that just because a full body search feels good that doesn’t make it right.
Show notes
1) Tools for practice
CT scans and other forms of low-dose ionizing radiation – What is the risk of cancer?
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In episode 137, James and Mike welcome Mark McConnell back to podcast land to discuss the latest change in diabetes management guidelines. Mark leads us through a great discussion about how the VA has decided to do a bit of an about face, and incorporate not only evidence but also patient values and preferences into their most recent glucose control guidelines. At the end we all agree that an A1C measurement, no matter if it is 7, 8, or 9, is just a number and is not the ultimate endpoint for proper diabetes care.
Show notes
1) VA-DoD Update of Diabetes Guidelines
2) Glycemic control in type 2 diabetes: time for an evidence-based about-face?
Ann Intern Med. 2009 Jun 2;150(11):803-8. Epub 2009 Apr 20
3) The ACCORD Trial and control of blood glucose level in Type 2 diabetes mellitus
In episode 136, James and Mike once again raise the content bar level with the premium of all PREMIUM podcasts. We talk about a study that looked at the effect of ezetimibe plus simvastatin and we get a very clear answer but unfortunately the question that was asked was completely wrong. We then bring the podcast to a rising never ending crescendo by discussing a “pivotal” trial comparing psyllium to prunes in chronic constipation and low and behold the answer is extremely useful and relevant to day-to-day practice.
Shownotes
1) SHARP TRIAL
2) The PRUNE trial
Aliment Pharmacol Ther 2011;33:822–8
3) An Evidence-Based Approach to the Management of Chronic Constipation in North America
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