Hyperlipidemia: Drugs for Cardiovascular Risk Reduction in Adults.

Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and the U.K. National Institute for Health and Care Excellence (NICE) indicate that lipid-lowering drugs have benefit for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) events. The evidence is strongest for statins. ACC/AHA, NICE, and U.S. Preventive Services Task Force (USPSTF) guidelines recommend statin therapy based on patients' risk of an ASCVD event, rather than treating to specific lipid levels. For patients with no previous ASCVD event, risk calculators should be used to determine the 10-year risk of ASCVD. The ACC/AHA guideline recommends starting moderate- to high-intensity statins if the risk is 7.5% or greater, whereas the NICE and USPSTF guidelines recommend statins if the risk is 10% or greater. Patients with known ASCVD should receive high-intensity statins unless they fall into special categories (e.g., older age) or do not tolerate high-intensity statins, in which case moderate-intensity statins are appropriate. Liver transaminase levels should be checked before starting statins; guidelines vary on if and when to recheck them in the absence of symptoms. Lipid levels should be rechecked one to three months after starting statins, although guidelines differ on subsequent checks. Other lipid-lowering drugs (e.g., bile acid sequestrants, ezetimibe) can be considered if patients do not tolerate statins. Niacin should not be used. Some evidence supports adding ezetimibe to statin therapy in patients with acute coronary syndrome or chronic kidney disease. The role of proprotein convertase subtilisin/kexin type 9 inhibitors is unclear, but initial studies suggest a decrease in the rate of acute ASCVD events in patients with hypercholesterolemia.

Pharmacologic treatment of hyperlipidemia.

Pharmacologic treatment of hyperlipidemia in conjunction with therapeutic lifestyle changes can be used for both primary and secondary prevention of cardiovascular disease. Statins have the most convincing data for primary prevention, especially for higher risk patients. Therefore, risk stratification is essential. Statin therapy is also recommended for secondary prevention in all patients with known cardiovascular disease or the risk equivalent. High-dose statins should be initiated in patients with acute coronary syndrome. Omega-3 fatty acids may be a good alternative after myocardial infarction for patients who cannot tolerate statins. Fibrates and niacin have not been shown to reduce all-cause mortality in secondary prevention, but may be useful adjuncts when statins alone cannot adequately control lipid levels. Other cholesterol-lowering medications used for primary or secondary prevention of cardiovascular disease have not been shown to consistently improve patient-oriented outcomes. There is good evidence for using statins in the secondary prevention of stroke and peripheral arterial disease.

Choosing topical corticosteroids.

Topical corticosteroids are one of the oldest and most useful treatments for dermatologic conditions. There are many topical steroids available, and they differ in potency and formulation. Successful treatment depends on an accurate diagnosis and consideration of the steroid's delivery vehicle, potency, frequency of application, duration of treatment, and side effects. Although use of topical steroids is common, evidence of effectiveness exists only for select conditions, such as psoriasis, vitiligo, eczema, atopic dermatitis, phimosis, acute radiation dermatitis, and lichen sclerosus. Evidence is limited for use in melasma, chronic idiopathic urticaria, and alopecia areata.

Metformin as treatment for overweight and obese adults: a systematic review.

PURPOSE: We wanted to determine whether metformin is an effective medication for treatment of overweight or obese adults who do not have diabetes mellitus or polycystic ovary syndrome (PCOS). METHODS: We searched MEDLINE (1966-2003), EMBASE (1986-2003), Allied and Complementary Medicine Database (1985-2003), International Pharmaceutical Abstracts (1970-2003), the Cochrane Library, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Controlled Trials Register, MEDLINE In-Process & Other Non-Indexed Citations, reference lists of retrieved articles, and articles by selected authors and pharmaceutical manufacturers. Inclusion criteria were being obese or overweight determined by a BMI of 25 kg/m2 or greater or waist-to-hip ratio (WHR) of more than 0.8, metformin use, and aged 18 years or older. Exclusion criteria were a diagnosis of diabetes mellitus, polycystic ovarian syndrome or descriptors of polycystic ovarian syndrome, human immunodeficiency virus infection, and concomitant antipsychotic medications. Trials were graded on an 11-point Jadad scale. Only randomized controlled and blinded trials were accepted. Two reviewers independently extracted data from each trial. Primary outcomes measured were changes in BMI, WHR, and weight. RESULTS: Fifty-seven potentially relevant studies were initially identified; 48 were excluded because of lack of randomization, lack of blinding, failure to meet inclusion or exclusion criteria, inaccessible outcomes, or improper study design. Nine clinical trials met criteria for validity assessment. Four studies used the parameter of waist-to-hip ratio, 3 studies included BMI, and 8 used weight. Two of the 9 studies showed a small reduction in WHR. CONCLUSION: Insufficient evidence exists for the use of metformin as treatment of overweight or obese adults who do not have diabetes mellitus or polycystic ovary syndrome. Further studies are needed to answer this clinical question.

West Nile virus infection.

PURPOSE: The epidemiology, virology, and transmission of West Nile virus (WNV) are reviewed, and the clinical features, diagnosis, and treatment of WNV infection are examined. SUMMARY: WNV infection is caused by a flavivirus transmitted from birds to humans through the bite of culicine mosquitoes. WNV was discovered in the blood of a febrile woman from Uganda's West Nile province in 1937. The first case of domestically acquired WNV infection was reported in the United States in 1999 in New York. Since then, WNV infection has spread rapidly across the United States, with 9306 confirmed cases and 210 deaths reported from 45 states in 2003. It is still not clear how WNV was introduced into North America. WNV is a small, single-stranded RNA virus and a member of the Japanese encephalitis virus antigenic complex. While most humans infected with WNV are asymptomatic, some may develop an influenza-like illness. Disease surveillance remains the cornerstone for the early recognition and control of WNV. We describe one case of WNV infection with an update on the disease. Strategies for the prevention and control of this infection are reviewed. CONCLUSION: There is no established treatment for WNV infection. Currently, prevention and control are the only measures that help decrease the morbidity and mortality associated with WNV infection. As the number of cases escalates and the geographic distribution of WNV infection widens, the epidemic will continue to pose a major challenge to clinicians in the coming years. There is an urgent need for more research on the pathogenesis and treatment of WNV infection.