Initiation of antihypertensive treatment during nonsteroidal antiinflammatory drug therapy

Initiation of antihypertensive treatment during nonsteroidal antiinflammatory drug therapy

CURRENT LITERATURE was a 19% decrease in the overall mortality rate from these cancers, with most of the decline occurring after 1979. Throughout the ...

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CURRENT LITERATURE was a 19% decrease in the overall mortality rate from these cancers, with most of the decline occurring after 1979. Throughout the interval mortality was much higher for men than for women and for blacks than for whites. Even though there was an overall decline, mortality rates increased among blacks, especially among black men. The South Atlantic, New England, and Mid-Atlantic states had the highest incidence of mortality while the mountain states had the lowest. Differences in the likelihood of developing these cancers seems to account for the disparity between male and female mortality from oral and pharyngeal cancer, while the differences between blacks and whites seems to come more from differences in survival than in incidence. Blacks and whites exhibit different age patterns of mortality. It seems mortality among whites, not among blacks, rises continuously with age. Mortality rates were reported to have fallen in recent years, while the incidence and survival rates have reportedly remained almost unchanged. This apparent inconsistency does not have an explanation. This finding may have resulted from declines in the incidence of oral and pharyngeal cancers that have been masked by improved detection.--W. BAST Reprint requests to Dr Goldberg: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, MS:K35, 4770 Buford Highway, Chamblee, GA 30341.

Epidemiology of Oral Candidiasis in HIV-Infected Patients: Colonization, Infection, Treatment, and Emergence of Fluconazole Resistance. Sangeorzan JA, Bradley SF, He X, et al. Am J Med 95:339, 1994 Oral candidiasis is the most common fungal infection in patients with human immunodeficiency virus (HIV) infection. The purpose of this prospective, observational study was to investigate the epidemiology of oral candidiasis and the effect of the treatment of thrush in HIV-infected patients. Ninety-two men with HIV were observed for a period of 1 year. They were examined, classified according to type of HIV infection, had risk factors identified, and thrush history and treatment history obtained. Oral sites were cultured at the initiation of the study and then monthly, or when thrush occurred. Candida albicans strains were typed by contourclamped homogenous electric field (CHEP) electrophoresis. Changes in strains were evaluated over time for association with particular anatomic sites, episodes, relapse after treatment, and colonization of sexual partners. A non-blinded, randomized comp~ison was made between treatment with clotrimazole troches and oral flucanazole. Differences in outcome related to treatment and significance of risk factors for development of thrush were analyzed by the chi-square test. The mean age of the population was 38.5 + 0.9 years. Twenty-eight percent had acquired immunodeficiency syndrome (AIDS), 31% had AIDS-related complex, and 41% were assymptomatic. Yeast colonized in 84% of patients. C albicans accounted for all isolates. Nineteen different C albicans strains caused 82 episodes in 45 patients. Clinical cure rates were similar between fluconizole (96%) and clotrimizole (91%), but mycologic cure was better with fluconizole (49%) than clotrimizole (27%). Colonization recurred with the same strain 74% of the time. Patients are usually consistently colonized with a single strain. Fluconizole is more effective in providing a mycologic cure, but recurrences frequently occur with the same strain despite therapy.--R.H. HAUG Reprint requests to Dr Kauffman: Veteran's Affairs Medical Center, 2215 Fuller Rd, Ann Arbor, MI 48105.


Initiation of Antihypertensive Treatment During Nonsteroidal Antiinflammatory Drug Therapy Gurwitz J, Avorn J, Bohn R, et al. JAMA 272: 781, 1994 Nonsteroidal antiinflammatory drugs (NSAIDs) are among the most frequently prescribed medications in the United States, accounting for almost 4% of all prescriptions filled among those aged 65 years and older. It has been estimated that 10% to 15% take prescribed NSAIDs. The antiinflammatoryproperties of NSAIDs appear to result from their ability to inhibit cyclooxygenase, a critical enzyme in the biosynthesis of prostaglandins which in turn act as local regulators of cell function. Although gastrointestinal bleeding and renal insufficiency are well described complications of NSAID therapy, its affects on blood pressure are less appreciated. There is good evidence to suggest an important roll for prostaglandin in the modulation of two major determinents of blood pressure: vasoconstriction of arteriolar smooth muscle and control of extracellular fluid volume. Approximately one third of whites and 40% of blacks older than 65 years have either isolated systolic hypertension or combined systolic-diastolic hypertension. Arthritis is the most common chronic condition affecting the elderly, and hypertension is the most frequently occurring coexisting condition in those who report arthritis. These population characteristics and the high prevalence of NSAID use among older persons emphasize the importance of studying the clinical impact of NSAIDs on blood pressure in the elderly. The results of this study showed subjects aged 75 years and older were significantly less likely to begin use of an antihypertensive agent than those younger than 75 years. Sex distribution between cases and controls were similar. Initiation of an antihypertensive agent was more likely for blacks and other races compared with whites. Of those subjects beginning on an antihypertensive agent, 41% had used NSAIDs during the 365 days before the index date, compared with 26% of control subjects. This risk increased with recency of NSAID use. A dose response relationship was observed, with the odds of initiation of an antihypertensive medication increasing with increasing average daily NSAID dose. The findings of this study suggest that NSAIDs may increase the risk for the initiation of antihypertensive therapy in older persons and that this risk increases with increasing NSAID dose. Based on findings of earlier epidemiologic and clinical studies, recommendations have been made to reduce NSAID use when clinically feasible to reduce the risk of gastrointestinal and renal adverse effects in elderly patients. Such advice may apply to blood pressure effects as well. When NSA1D therapy is necessary, the lowest feasible dose should be used for the shortest time necessary to achieve the desired therapeutic effect.--J.D. AFFENITO Reprint requests to Dr Gurwitz: Program for the Analysis of Clinical Strategies, Brigham and Women's Hospital, 221 Longwood Ave, Boston, MA 02115.

MR Imaging of Temporomandibular Joint Abnormalities Associated With Cervical Hyperextension/Ityperflexion (Whiplash) Injuries. Pressman B, Shellock F, Schames J, et al. J Magnetic Resonance Imag 2:569, 1992 Whiplash is the most common cause of injuries to individuals involved in auto accidents. Patients often have temporomandibular joint (TMJ) dysfunction-related symptoms following whiplash injuries caused by rear-end motor vehicle collisions. Thirty-three symptomatic patients (66 joints) with no direct trauma to the jaws due to the accident and no prior