Came across an interesting article via Medscape on atypical (subtrochanteric) femoral fractures in patients using bisphosphonates. It reviews a Swiss case control study of 477 patients aged 50 and over with hip fractures followed from 1999 to 2010 (11 years). Below are my take home messages:
Here are the key points from the Medscape article summarizing an observational study which showed an increased risk of sudden cardiac death for patients on a five day course of Azithromycin compared to Amoxicillin or no antibiotics:
- May 17, 2012 issue of the New England Journal of Medicine.
- The patients were aged 30 to 74 with a mean age 49, and 77% were women.
- Compared with patients receiving amoxicillin therapy, during five days of azithromycin therapy, there were an estimated 47 additional cardiovascular deaths per one million courses of therapy. Among patients in the highest decile of cardiovascular risk score, there were an estimated 245 additional cardiovascular deaths per one million courses of azithromycin therapy.
- The risks of cardiovascular death were similar for ciprofloxacin and amoxicillin and for levofloxacin and azithromycin.
- “the azithromycin risk returns to baseline on days 6 to10”
- The study was supported by a grant from the National Heart, Lung, and Blood Institute and a cooperative agreement from the Agency for Healthcare Quality and Research Centers for Education and Research on Therapeutics.
I happen not to prescribe Azithromycin much, as I see it fail a lot as an antibiotic. I prefer the older macrolides as they work better in my experience. Having said that would I stop prescribing Azithromycin based on this? Unlikely, The increase in risk is very very low and is not clinically significant in my opinion.
The risk of dying from an untreated pneumonia (see risk calculator) especially in the elderly is greater irrespective of other co-morbidities. If aged 65y the risk is 0.6 to 0.7% and that is without any co-morbidities at all. Divide the 245 by 1000,000 i.e. a .0245 % increase in risk. Do you see much of a difference between 0.6% and 0.6245% ? I don’t see a clinically meaningful difference.
It is a hot and sweltering afternoon in Jeddah and more than the odd patient seems to have opted to stay away for this afternoon. So left with a bit of time between the ones who have made it through I thought I would just have a quick read of the UpToDate entry on Diabetes and revise my daily practice. As I read I thought I would post to my blog. First point: Should we screen asymptomatic diabetics for silent heart disease with stress tests?
If you try and work out the risk of cardiovascular disease using the Framingham calculator or other tools such as QRISK then you when you come to entering your patient’s blood pressure you will see that the only number required is the systolic blood pressure. What happened to the diastolic blood pressure?