Monday, 28 March 2011

"To smoke or not to smoke?" is NOT the question.

"To be, or not to be" is the opening line of William Shakespeare's play Hamlet of the third act, scene one. Hamlet ponders over dichotomy of his options. Even though Hamlet was troubled a lot by his issues, thankfully there is no dichotomy amongst physicians when it comes to smoking cessation. Patients who smoke are told to quit often times by their physicians, nurses, family or friends. Many times it is not successful. Nowhere is the opportunity to quit smoking more evident than when there is a surgery looming on the horizon.
Any surgery compels even a chain smoking die-hard addict to quit. The reason is simple; you can't smoke in a hospital when you are recuperating in the post-operative period. I often take this opportunity to tell patients to quit smoking prior to any operative procedure. In fact a lot of surgeons (orthopedic surgeons, heart surgeons etc) want patients to completely kick off their habit even before they begin to talk about surgery.
Quitting smoking especially if you have ANY lung disease is tremendously beneficial. There is no doubt about that. Stopping smoking helps reduce blood pressure, reduces your stroke and heart attack risk.
The question is when to quit before surgery? few days? few weeks? Months? This seemingly simple question has a surprisingly difficult answer.

A study came out in 1989 from the UK which showed that people who quit smoking immediately before surgery had more issues after the operation than those that had quit long time before2. Thus quitting smoking immediately before surgery carried a poorer outcome for post surgical patients!
In an interesting article that came out in Journal of American medical association (JAMA)1, Myers and her group did analysis of existing smoking trials to look for common patterns emerging from these studies. Nine studies were selected with a pooled patient number of 889.
Results of the study show that there was no change in outcome if you continued to smoke or quit smoking just prior to surgery. This result goes against the earlier work and shows that there is no harm in stopping smoking immediately before surgery. The best benefit is if you have not been smoking for a long time (months to years) prior to surgery.  
So what are you waiting for? To smoke or not to smoke is not the question because it has has an easy answer. DON’T!
1.    Stopping smoking shortly before surgery and post-operative complications. A systematic review and meta-analysis. Katie Myers, Peter Hajek, Charles Hinds and Hayden Mc Robbie. J. Arch Intern Med. 2011 Mar
2.    Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Warner MA, Offord KP, Warner ME, Lennon RL, Conover MA, Jansson-Schumacher U. Mayo Clin Proc. 1989 Jun;64(6):609-16.

Saturday, 26 March 2011

Clinical trial: Preventing COPD exacerbations, drug comparison

SPIRIVA was SUPERIOR to SEREVENT in prevention of COPD attacks in moderate and severe COPD patients.

What is COPD?

COPD stand for chronic obstructive pulmonary disease. There are 2 diseases included in COPD, these are emphysema and chronic bronchitis. Emphysema is defined in pathologic terms and is defined as destruction of the air sacs of the lung responsible for oxygen transfer into blood. Chronic bronchitis on the other hand is a clinical diagnosis with it being defined as cough with productive sputum (phlegm) for 3 consecutive months in 2 consecutive years.

there are many treatments available for COPD and involved usually a combination of a longer acting controller and a short acting rescue drug.

If you have been diagnosed with COPD, print this out. checklist for COPD

In the New England Journal of Medicine (march 2011 issue). Vogelmeier and his group have compared 2 effective inhalers for prevention of COPD attacks.

Attacks of COPD are essentially spells of increased shortness of breath and cough with sputum and can be triggered by infections, allergies or irritants in the air. Both tiotropium inhaled (know as SPIRIVA in USA, Boehringer Inc) and Salmeterol (known as SEREVENT DISKUS in USA, GSK) are recommended as controller medications for moderate to severe asthma.

A few studies have been done in the past which showed no difference in outcomes between the two but these were shorter term studies 3-6 months. This study compared head-to-head if one was better than the other and followed patients over a year. The group gathered data from about 6000 participants who were selected based on specific selection criteria.

Comparison goals were time to first attack, number of attacks, deaths and time for attack to subside.

Here are the results:

1. probability that patient will discontinue the medication was LOWER with SPIRIVA

This means that patient stay longer on the medication and get helped more.

2. Time to first exacerbation was LOWER with SPIRIVA

patients with SPIRIVA had exacerbations on an average 42 days later than those on SERVENT. This means SPIRIVA tends to control the COPD better than SERVENT.

3. Annual rate of exacerbations was LOWER with SPIRIVA

There were 11% MORE exacerbations when patients were on SERVENT


SPIRIVA was SUPERIOR to SEREVENT in prevention of COPD attacks in moderate and severe COPD patients.

Both SPIRIVA and SERVENT act to expand the air ways and improve air flow. SPIRIVA acts but blocking the cholinergic nerves while SERVENT acts by stimulating the adrenegic nerves. This study compares the two and provides good evidence that tiotropium is better. Thought there may be a difference in the way the drug reaches the lung and would have affected the results but the bottom line is that tiotropium did better than salmeterol.

Talk to your doctor! see what works out for you!! and oh yes DONT SMOKE if you have COPD.

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Things to do if you have been diagnosed with COPD

Here is a quick checklist of some do's and dont's:

1. Co-ordinate your care with your doctor
2. Do NOT smoke! Smoking accelerates the lung damage. (this measure extends life). seek help to quit.
3. If you have been placed on home oxygen make sure you use it (this measure extends life)
4. Controllers (steroids and long acting agents to be used daily), see which long acting agent is better! Spiriva versus Serevent.
5. Rescue inhalers (albuterol, combivent when breathing is worse)
6. Recognize symptoms of COPD exacerbation-seek medical attention.
7. Eat healthy.
8. Get seasonal flu vaccines every year and the pneumonia shot.
9. Pulmonary rehabilitation.

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