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Levonorgestrel Coil To Enter NICE Guidelines As First Line Option For Heavy Menorrhagia Treatment

MD-FM Thursday January 10, 2013





GENERIQUE
Carillon
 
Sarah:
MD FM — Medical News from around the world with Peter Goodwin.

P1

PETER:
Hello, and with me is Sarah Maxwell. To begin with, for patients with menorrhagia, the levonorgestrel-releasing intra uterine system could be a new standard treatment…

SARAH:
Yes this device was more effective than traditional medical treatments in a randomized trial published in the New England Journal of Medicine. It compared the levonorgestrel IUD with either: tranexamic acid, mefenamic­acid, combined estrogen and progestogen or progesterone alone. At two-year-follow-up, the oral treatments were effective in women and improved their quality of life — but the coil was 13 points more effective. The next follow-ups will be at five and 10 years of treatment.

PETER:
Hmm, it sounds promising, what about side effects?

SARAH:
Well: not too many, lead study author Janesh Gupta told us:

Bob-Gupta: “Up to 3 to 6 months after the coil is fitted, there is a slightly higher risk of irregular periods that women will complain of, and most women will accept that if you pre-warn them. That is the most common side effect. There’s also been a previous concern that putting IUD caused pelvic infections... In fact that’s not a major concern because we now recognize that we should screen women for infections before we put the coil in, and it’s not actually the coil itself that is inherently causing infection, there’s been pre-existing infections that have been flared up by using a coil. So this concern that women may have ‘oh I’m having a coil and it may increase my risk of infections’ -is not true”

SARAH:
Professor Gupta also outlined some clear conclusions for the future:

Bob-Gupta: “In the UK, we are going to be changing our NICE guidelines to say that as first line therapy, for women who don’t want to get pregnant, because it’s a contraceptive, this coil should be the first line treatment used by primary care physicians, because it is very effective. If women want to get pregnant, then they should use tranexamic acid, which is also effective, but not as effective as having a coil fitted. So that’s really the bottom line.”

SARAH:
Professor Janesh Gupta, from Birmingham University in the UK.

P2

PETER:
For women considered at high-risk of ovarian or fallopian tube cancer, the need for strict adherence to annual screening schedules has been highlighted in a prospective study with over 3,500 people. Results published in the Journal of Clinical Oncology show, screening more than once a year, with prompt surgical intervention, offers a better chance of early-stage detection then less frequent schedules.

VIRGULE MUSICALE

P3

PETER:
For patients with diabetes and coronary artery disease, the use of metformin significantly reduce the risk of cardiovascular events compared to sulfonylureas…

SARAH:
Yes, after a median follow-up of five years, metformin reduced the primary composite endpoint of: death from any cause, death from cardiovascular causes, non-fatal myocardial infarction, non-fatal stroke, and arterial revascularization by 46% compared with glipizide. That’s from a randomized trial published in Diabetes Care, and Professor Eric Rénard — a diabetologist who didn’t take part in the study — gave us his assessment:

Bob-Renard: “This further confirms that the first line of drugs to be used in diabetic patients is metformin --it is costless, very efficient, very effective on cardiovascular risks, and for each patient with type 2 diabetes using metformin is really a chance. So all efforts should be done so that most type 2 diabetic patients should use this drug.”

SARAH:
That was Eric Renard, from the University of Montpellier, in France. Patients treated with metformin needed much lower doses of statins compared to patients on glipizide, a finding that added strength to the study.


VIRGULE MUSICALE
 
P4

PETER:  
SSRI anti-depressants taken during pregnancy, do NOT increase the risk of stillbirth or infant mortality…

SARAH:
Yes that’s from a study — published in JAMA — with almost 30,000 women from Nordic countries taking SSRIs during pregnancy. Researchers compared birth outcomes — focusing specifically on stillbirths, newborn and infant deaths — in women who took SSRIs and women who didn’t, and they gathered information on SSRI use from prescription registries:

Bob-Stephansson-1: “When we first looked at it there was a small small increase in the rate of stillbirth and postnatal mortality among women with these SSRIs but when we controlled for the fact that they were older, that they were more often smokers and foremost that for disease severity we found no increased risk with the drug itself.”

SARAH:
That was lead investigator Olof Stephansson of the Karolinska Institute in Sweden, who added that previous evidence has shown SSRIs are associated with other — very rare — birth defects such as pulmonary hypertension and withdrawal syndrome:

Bob-Stephansson-2: “If a woman needs these drugs, I think that you may use them, but you have to have a discussion with the woman in early pregnancy. If you choose a drug among these SSRIs you should not use peroxytin, you should use some of the other drugs, and keep the dose as low as possible, and of course it’s possible you could try without but… if a woman needs these drugs then from what we know today, she would feel better from taking them today instead of having a more severe psychiatric disease which might be even more harmful to the mother and the baby.”

SARAH:
Professor Olof Stephansson, from Stockholm.

VIRGULE MUSICALE

P5

PETER:
The Atlanta classification for patients with acute pancreatitis has been revised, and defines three levels of disease severity and the local complications that can follow…

SARAH:
A working group has come up with an international consensus on different levels of severity: mild, moderate or severe. The classifications — published in Gut — also agreed about the relevance of local complications that can occur in very severe pancreatitis: peri-pancreatic fluid collections, pancreatic and peri-pancreatic necrosis, pseudo-cyst and walled-off necrosis. Lead study author Michael Sarr:

Bob-Sarr-1: “In the past, the term pseudo-cyst has been used for virtually all of them, because no one has come up with an objective way to describe these complications. And they’re very important because each type of complication has a different treatment.”
 
SARAH:
Doctor Michael Sarr, from the Mayo Clinic in Rochester, Minnesota. And the take-home for busy doctors?

Bob-Sarr-2: “We hope that the practicing clinician will use this by, first, recognizing there are two types of pancreatitis: oedematous pancreatitis, which is harmless, and necrotizing, which can be potentially serious. Second: the severity can be anticipated when they hit the hospital. And then the third is: If they are in this category of moderate of severe acute pancreatitis, when they image the patient, with contrast enhanced CT or magnetic resonance imaging, differenciation of these peri-pancreatic and pancreatic collections collections is quite important because you treat each one differently.”
 
SARAH:
Michael Sarr, from the Mayo Clinic.


BREVE 1 Sur fond musical

PETER:
Finally, in brief:
A new recombinant form of human relaxin 2 could benefit patients with acute heart failure. Serelaxin reduced shortness of breath at five days compared to placebo according to findings from California published in The Lancet and recently reported at the American Heart Association. There was no difference in cardiovascular death or hospital readmission for patients with heart or renal failure through to day 60, however, at six months, cardiovascular deaths were significantly lower in patients on serelaxin.

And…

BREVE 2

For patients with acute upper gastrointestinal bleeding, a restrictive transfusion strategy — starting    only when hemoglobin levels fall below 7g per deciliter — significantly improved outcomes, compared to a liberal strategy — which waits for hemoglobin to fall below 9g per deciliter. That’s from a randomized study from Barcelona, published in the New England Journal of Medicine.

That's all from MDFM for now. Sarah Maxwell and I will be back with more next week, so until then from me Peter Goodwin, goodbye!
 
JINGLE FIN     
 

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