Holbrook and colleagues provide an updated systematic overview of drug and food interactions with warfarin, including the quality of evidence and clinical importance. The literature quality continues to be very poor, based mostly on individual case reports. Despite the poor quality, the consistency of reports of interactions with drugs (including azole antibiotics, macrolides, quinolones, nonsteroidal anti-inflammatory drugs including selective cyclooxygenase-2 inhibitors, selective serotonin reuptake inhibitors, antidepressants, omeprazole, lipid-lowering agents, amiodarone, and fluorouracil) suggests that coadministration with warfarin should be closely monitored or avoided altogether.
Armstrong and colleagues examined the extent to which data collection may be affected by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule using a quality-improvement registry of patients with acute coronary syndrome. The authors found that patient consent for follow-up within the registry declined significantly from 96.4% in the pre-HIPAA period to 34.0% in the post-HIPAA period. In addition, patients returning written consent during the post-HIPAA period were older, more likely to be married, and had lower mortality rates at 6 months. Thus, the HIPAA Privacy Rule may decrease the number of patients available for outcomes research using quality-improvement registries and may introduce selection bias in the data collection.
There is debate over the types of physicians who should treat patients with complex chronic medical conditions, such as human immunodeficiency virus (HIV) infection. Landon and colleagues examined the influence of both formal training and expertise (including caseload) on the treatment of a representative population of 5247 patients with an HIV infection receiving their care at 64 clinics funded through the Comprehensive AIDS Resources Emergency Act throughout the country. Generalist physicians with expertise in HIV infection provided care of equal quality to specialists trained in infectious diseases on multiple important components of outpatient care for HIV infection. Developing strategies to obtain appropriate expert input for patients who receive care from nonexpert generalists might also lead to improved outcomes.
Sherman and colleagues describe the frequency and characteristics of stroke events occurring during the AFFIRM study, comparing rhythm to rate control strategies. As with mortality, the primary end point, there was no significant difference in stroke rates between the rhythm and rate control groups. The discontinuation of warfarin therapy anticoagulation based on the assumption that sinus rhythm was successfully established was associated with an increased risk of stroke. Patients with atrial fibrillation and predictors for increased stroke risk should continue receiving anticoagulation therapy even if they appear to be in sinus rhythm.
The National Institutes of Health National Cholesterol Education Program recommends dietary supplements such as soluble fiber to help lower cholesterol levels, particularly low-density lipoprotein cholesterol (LDL-C) levels. Psyllium husk is a rich source of soluble fiber and is the active ingredient in Metamucil (The Procter & Gamble Company, Cincinnati, Ohio) and other fiber supplements. In an 8-week study of 68 patients, 3 servings of Metamucil a day were added to the diet of patients already taking simvastatin. Psyllium was able to lower LDL-C levels by 6% in addition to the lowering results seen with the statin, and the lowering results were equal to those from doubling the statin dose. High-density lipoprotein cholesterol levels were unchanged, and adverse effects were reported more in the placebo group than by patients taking psyllium soluble fiber. Psyllium supplementation should be considered as a safe and well-tolerated dietary option to enhance LDL-C lowering.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2005;165(10):1086. doi:10.1001/archinte.165.10.1086