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What are the latest advances in the treatment of migraine, stroke, diabetic peripheral neuropathy, and enlarged prostate? These were some issues addressed by the American Medical Association at its Annual Science Reporters Conference, held recently at the National Press Club in Washington, D.C. Here are the highlights:
Mark W. Green, M.D., director of the Columbia University Headache Center, opened the program with an update on migraine therapy. According to Green, migraine headaches represent a spectrum of symptoms, including, for example, not only migraines with aura (which occur in only 15% to 20% of migraine patients), but also tension headaches, neck pain, and even sinus headaches. He indicated that there is no scientific validity to the term "sinus migraine." A number of migraine patients, he said, present with nasal congestion and eye tearing along with their attacks, driving them to take OTC sinus drugs for this "non-disease." Some physicians, Green added, recommend periodic treatments with antibiotics for people who clearly have migraines. "This concept of sinus headache is not seen in other countries of the world."
The overall principle in treating migraine with the triptan class of agentsthe current gold standardis to treat early and to treat at a high dose. In this regard, Green noted, "the principle of step care is a big mistake and such a therapeutic approach likely would result in too little, too late." He feels that step therapy or self-therapy with OTC medications "only sets migraine patients up for chronic migraines down the road."
In terms of future therapy, Green noted that about 12 different receptors are being evaluated. Of these, he believes that the calcitonin gene-related peptide-receptor antagonists represent a potentially interesting class of new pharmacologic agents for acute migraine therapy.
Bruce Perler, M.D., professor of surgery at Johns Hopkins University, presented breaking news regarding "statins and stroke risk in carotid artery surgery." Perler's group performed a 10-year retrospective analysis of stroke incidence and stroke-related mortality in patients undergoing carotid endarterectomy. Findings indicated that patients on statins had a significant reduction in both perioperative and 30-day postoperative stroke incidence compared with non-statin patients, and a fivefold reduction in stroke-related mortality. He went on to note that available clinical data suggest that "statins can be used to prevent strokes in patients with abnormal cholesterol levels and even in patients with normal cholesterol levels." Traditionally, statins are targeted toward reduction of myocardial infarction via cholesterol reduction. In the case of stroke prevention, and particularly in the case of stroke prevention post-endarterectomy, the pleiotropic effects of statins may contribute to their benefits.
The topic of diabetic peripheral neuropathyand, specifically, improving the quality of life in the estimated 60% of diabetic patients who ultimately suffer from this conditionwas covered by Sean Mackey, M.D., Ph.D., associate director of the pain management division at Stanford University. Mackey indicated that "diabetic neuropathy is a tremendously underdiagnosed and undertreated progressive condition that has a huge impact not only on the patient but on society as a whole." This occurs despite proven, available means such as tricyclic antidepressants, anticonvulsants and miscellaneous agents such as clonidine and mexiletine, and even capsaicin, all of which lack a specific indication to treat diabetic neuropathy; and the recent approval of two new medications with a specific indication, namely duloxetine (Cymbalta, Eli Lilly) and pregabalin (Lyrica, Pfizer). Mackey foresees future management of this condition based on a multidisciplinary approach with agents capable of preventing and even reversing damage to peripheral nerves and associated blood vessels.
Misop Han, M.D., assistant professor of urology at Northwestern University, provided insights into "awareness and advances central to treating enlarged prostate (EP)." Han indicated that the increased incidence of EP seen currently is likely due to "men living longer in the United States; that it is more common in older men, so we are detecting a greater number of cases; and that men are more readily seeking the advice of a physician." Initial workup of EP focuses on ruling out prostate cancer in lieu of benign prostatic hypertrophy (BHP). Pharmacotherapy of BPH is based on the relaxation of prostatic smooth muscle via α1-adrenergic receptor blockers or via 5α-reductase inhibitors, which inhibit the conversion of testosterone to dihydrotesterone. Side effects include dizziness and postural hypotension for the α1-adrenergic receptor antagonists and decreased libido and erectile dysfunction for the 5α-reductase inhibitors. Combination therapy with both classes of agents has been associated, according to Han, with "significant reduction in all of these urinary problems as well as potential side effects than using either alone."
Stephen Setter, Pharm.D., an associate professor at Washington State University, indicated in a subsequent interview that current therapies for BPH are limited in that "we don't want to impact blood pressure in a patient who does not have a hypertensive issue" in the case of the α1-adrenergic receptor blockers, and that "patients don't really want to wait" for the 5α-reductase inhibitors to significantly shrink the prostate.
THE AUTHOR is a healthcare communications specialist residing in Montville, N.J.